Sylvia's Journal

The young girl with the pretty shoe has returned, this time with her papa and grandma. It is the second testing of her new leg.  It takes a while to put it on.

I asked if I could take some pictures. Grandma said no, but the girl, looking for permission from dad, nods yes.  She puts the leg on herself, not yet an easy thing to do. She then walks hesitantly between the two even exercise bars places in the middle of the room.

The motto at this hospital is ‘the patient is the center of our attention.’ It is a slogan but I don’t really see that here. The chief of the center, who is preoccupied with preparing for her trainer’s role later this morning, is not paying much attention to the girl and her father. Maybe I am the center of attention, and pleasing me is what counts. I hope not but it is very possible. I suggest she helps the girl put the prosthetic on correctly, as the first walk did not go well.

The (international) ICRC expert takes a look and shows her how to make the knee lock and unlock on her own. It is all about learning to do things for oneself, he says. Patients are not served if we do things for them. He then watches and corrects her gait and shows how her steps are of uneven length. He draws lines on the floor with a marker to show where her shoes should be at every step, toes one way, heels on the way back. He is very involved with her (the patient in the middle), unlike any of the other staff of the center.  I see that the challenges are not only managerial but also a lack of understanding of what the slogan (focus on patient) really means in terms of one’s behavior. Later I also discover that technical competence to diagnose and treat, is very limited.

Another man comes in, he has diabetes and lost his foot – he is waiting to make a plaster form of his stump but I am told this cannot be done and he has to come back, because Tuesdays are plaster days, not Thursdays. He is accompanied by the only physiotherapist in the hospital; the one whose only staff consists of two blind PT aides. I learn later that all they can really do is massages, as a blind person is of little use to check a person’s gait.

It is busy today because it is market day. In the past there were sometimes only 2 or 3 patients per months. Now I am seeing three all at once. With the help of ICRC the place is taking off. The man for whom the large prosthetic was made shows up and with great ease put on his new leg and walks away to practice outside. He is far ahead of the young girl, making her first awkward steps.

More are coming: a 4 year old girl riding on the back of her mom. She sustained some minor brain damage at birth and walks with difficulty, her foot arches collapsed. The mother gives a small sandal to the assistant. She was told an orthotic would help. My ICRC colleague says she needs PT. Another woman comes with a baby on her back that had his clubfeet corrected. For the next few years he has to sleep with a metal bar with shoes attached that will ensure his bones grow properly. At four years old no one will be able to tell he was born with clubfeet. This is the specialty of CURE hospital here.

Today we have planned the second module of our Leadership Program, the same as last week in Niamey. The program was supposed to start at 11AM in the main conference room but when we went there to set things up we could not enter. The DG, faced with an impromptu visit from the labor union, has requisitioned the room. It took at a while to figure out where to go. Several department chiefs offered their conference rooms. Everywhere cleaners were dispatched to clean these rooms. In the meantime we waited under a tree for instructions on where to go, while the temperature rose and rose. Lethargy swept over the hospital. Everywhere people were sleeping on mats, on chairs, or simply on the ground.

A very young girl arrived with her parents – she walked with a limp. The PT happened to be there and he asked the girl to pull up her skirt and walk. She too was the victim of an injection gone awry. Luckily, he told me later, exercises will be able to correct her posture and get rid of the limp.

Our team here spent a good deal of yesterday and this morning preparing, writing their flipcharts in large script, running out of space, having to do it over again – drawing a schematic several times until they get it right.

We practiced the visioning session – where people have to draw their vision of the center. Dj. is utterly stumped. Eventually she draws a kind of architectural plan of the new (dream) center, with some difficulty. I explain how individual visions are shared and then turned into a shared vision. It is such a novel concept. Luckily this session is facilitated by the young ICRC program assistant who is now the master trainer. He has done this module last week in Niamey. I see him grow in confidence in front of my eyes. He is now helping his co-trainer to prepare and become more confident.

I asked her to rate her level of confidence on a 10 point scale. After some hesitance she says ‘in the middle.’ When I insist on a number she says ‘a 7.’ I ask her what it will take to move to an ‘8.’  She utters a few clichés, like ‘become more confident, ‘have ‘sangfroid,’ ‘get out of my comfort zone,’ while I keep asking ‘but how?’  I keep hoping she says ‘through preparation,’ but she doesn’t and so finally I utter the word. ‘Oh, yes, of course she says, ‘preparation!’

The young ICRC assistant is also the logistician, organizing handouts, materials and something to eat and drink during a brief lunch break. I love how he says, ‘pas de souci,’  because I know he is right; I need not worry because he has taken care of things. He is reliable and honest, now he needs to learn to speak more audibly and with more confidence.

We just learned that we have seats on the UNHAS flight tomorrow. I had been a little nervous about that given our delayed flight coming out. With UNHAS nothing is guaranteed and one knows only 24 hours in advance whether the trip is on or not.  The only alternative to flying is a 14 hour bus ride that starts at 4AM in Zinder and arrives early evening in Niamey. That is, if all goes well, ‘incha’allah’ they say here, because life is full of surprises and unexpected turns of events, and God only knows (and wills).

We had a nice local lunch (rice with a tomato-peanut sauce) in another guesthouse. This is the place, I was told, where the very humble and no-fuss American ambassadress likes to stay when she tours the country. My ICRC colleagues have traveled with her (“she is like Condoleeza Rice,” which I took to mean that she is an African American). “She didn’t even want to wait in the VIP room at the airport, and she traveled with us in the UN plane, on a regular seat like everyone!” they exclaimed. This is of course not very African. When one has status one uses it. VIP salons, red carpets, news coverage, first class and front row seats, respect, especially respect, is what one gets when one is at the top.

We are not staying in this lovely guesthouse, a simple mudbrick structure with traditional decorations – so much more tasteful than our guesthouse, because of security concerns according to my ICRC colleague. I was surprised that the American embassy security people did not protest. At any rate, this I have learned in Afghanistan: if people want to blow you or your guesthouse up, no security detail can prevent it. The security at the guesthouse where we are staying didn’t strike me as all that much different or effective. In most countries I travel to, life is simply not safe. Period.

As if to illustrate this, I met a young woman and her grandmother at the rehab center. The girl had come back to try out her prosthetic leg which I had already seen  standing in a corner; a small left leg with a pretty shiny white shoe attached, a shoe with a gold clasp, a party shoe. It stood, somewhat incongruously, in a corner of the ‘walking school’ room, next to a giant leg that must be for a basketball player. The disembodied leg with its party shoe told a tragic story. The girl had been sick and received an injection. I remember from our days in Senegal that people there were great believers in injections and there was even a professional category of ‘injectionist.’  When people have a malaria attack they receive quinine injections twice a day – sometimes administered by people who do not know where the nerves run, or who use dirty needles. The injection can be put in the wrong place and lead to paralysis, irreversible, or cause an infection.

This girl had bad luck. The needle was probably dirty and caused an infection that was not treated. Eventually the entire leg had to be amputated. But it could also have been a traffic accident, or a simple household accident, or simply a small wound that gets infected as the climate is warm and the body is humid and bacteria love this combination. ‘So not necessary,’ I think, ‘so utterly not necessary.’ And yet, it’s what happens daily a thousand times over. And now I am not even talking about the self-inflicted wounds of armed conflict. Those people also show up. But that girl, that leg with the pretty shoe, it’s a haunting image.

I had been struck by the cleanliness of the hospital grounds – it is rare to find the little plastic bags that are filled with water, and when finished, dropped on the ground. You see them everywhere, but not here.  As soon as you pass the gates of the hospital all the usual detritus is gone. According to one of my colleagues, this feat was accomplished by the director, irately, going from place to place and shaming people into cleaning up. Apparently it is an approach that works (enlightened dictatorship it is called – It works in Rwanda, so why not here). But it is an approach that makes me cringe.

I am still struggling to figure out what makes sense here given the many (and complicated) moving parts of the project created in Geneva. For example, what to do with the participatory management systems assessment that is supposed to be filled in by a cross section of the organization’s personnel? Should we do it even with two or three persons because I said so or because it is on the to do list? I realize the futility of doing the assessment as it would violate most of the basic principles of the tool. But then again, this has also happened with the leadership program in Madagascar, and yet, I was pleasantly surprised by its effects. As an alternative I propose to introduce it to the hospital manager, may be it is of interest to him?

We worked this morning on preparing the second of the ten modules of the leadership development program. It will be taught by one person I observed in Niamey and the chef here who is part of the Essential Management Package (EMP) team of Niger (two in Niamey, two here and two from ICRC). One of the members of the team here in Zinder prefers to be a participant.

At breakfast I asked my ICRC colleague what he hoped to achieve during this visit. We are setting the bar low to make sure we succeed. Some of those things we discussed at breakfast we achieved before noon: a formulation of what the team will achieve as a result of the program: to ensure a full multi-disciplinary package of services for all patients who enter the rehab center. Right now services are incomplete as there is no guarantee that a physical therapist is at hand to help patients learn to function with their new artificial limb.

After we had dropped off our bags at our guesthouse we drove to the hospital where the small rehab center is located. We found all four staff there, two of whom I trained in Lome in June, to become better ‘managers who lead’ and make their center more efficient and effective. After I had the tour of the premises, simple but orderly, and more spacious than the center in Niamey (but with way less patients) – we sat down to discuss the baseline data they should have had collected and sent to me more than a month ago.

The instructions and excel sheets they should have filled in are on a flashdrive, given to the participants back in June. Flashdrives assume one has a computer to download the files on, and, at a minimum, to view them. This, we discovered, had not happened. The woman in charge of the center does not have a computer at work – there are no computers at all. But she had one at home which is now gone with her son who is studying in Morocco. She had mostly forgotten what had been delivered in a long monologue using powerpoints by the chief from Geneva. This of course was no surprise. Powerpoint-driven monologues don’t teach – we know that, yet we keep thinking that one day they will.

The project also asks teams to use a participatory organizational assessment of management systems that is developed by my organization. If in Niamey many of the items to be scored were irrelevant because the center is part of the hospital and management processes are run by the hospital, not the center, here this is even more so the case. The center’s manager had scored everything, on her own. We explained that the idea was to do this with others to help people see the whole as opposed to only seeing what happens in their own department (usually adequate) and what happens in other departments (nearly always lacking).

The idea of the three year project is to collect baseline data now (time and cost of making a prosthetic arm or leg, number of patients, use of raw materials, wastage, staff productivity, etc.) in order to determine two things: what should be the focus of the efficiency and impact improving intervention, and to be able to compare at the end of year 1,2 and 3 whether there has been any improvement.

Like other projects, the idea is good, but the conditions on the ground mess things up. Here we reviewed all possible interventions, not necessarily based on data (since they have not been collected) but on common sense about what is and what is not possible. We are aiming for (very) small victories.

In a steep hierarchical organization, where the boss is The Boss, leadership at lower levels, by people who are physically near The Boss, may well be a good theoretical idea, but not all that practical. I listened to the stories of how powerless people actually are when The Boss wants something.

I learned that technicians in prosthetic and orthotic workshops are excellent fixers. They can fix any broken equipment. The Boss likes this and sends any broken equipment from the entire hospital to the rehab center to be fixed by one of the four employees of the center – the one who makes the artificial limbs. This distracts from the work he is hired to do, but he can’t say no to The Boss. Nor can his boss, the woman who runs the center. Is it because she is a woman, I asked? No, not that, one simply cannot say no to the The Boss. I was thinking of my experience in Madagascar with the folks who were far from the center being able to take on a leadership role in their community. I now realize it is because The Boss there was very far away, and never showed his (or her) face. But here, where The Boss is close, it doesn’t work that way.

They do find ways to work around it. For example, Mr. Fixit now says to The Boss that he has tried but cannot fix it, a white lie, but effective. Or he makes the problem worse, a kind of organizational sabotage that doesn’t really serve anyone, but what else can one do?

Being here in this faraway place makes me think about what, of all the lofty intentions that we state in reports and proposals, we can actually do. We are one more of those signs on the road that clamor to deliver on promises and make lives better, but we too may find ourselves a rusted sign in the cemetery of failed or incomplete projects.

My philosophy has been to help individuals become more confident and, as a result, assertive and give them some concepts and tools they can use in their advocacy for humanizing workplaces and reducing stress. That’s really what coaching is all about and that is why I think coaching will make a bigger difference than anything else. And so I practice my coaching, not always successful, but I am learning from my mistakes.

We arrived in the middle of the afternoon in Zinder, after flying for about 100 minutes over hardscrabble lands. I could see the neat squares and rectangles below indicating someone was cultivating something. Given the environment, the sand, the scrubs and the rocks, it made one admire the resilience and adaptability of human beings; not an easy existence.

The airport in Zinder made me think of the atmosphere painted by V.S. Naipaul in his book A Bend in the River – sleepy, dusty and old.

We were about 16 people on the plane and for a moment the tiny airport livened up. Inside the hall were rows of plastic bucket chairs, originally bright orange but now faded and speckled from time and use. I remember those from airports closer to my home when I was young(er).  The ceiling is held up by a few enormously tall pillars – as if a second floor was planned but never executed. Four large baggage scales took up a considerable amount of real estate. Why four? I wondered. My co-traveler told me they were for the various airlines. Like who flies here, other than the UNHAS plane that took us? Well, there is Niger Airways, and then some others I had never heard of.

I weighed myself on one of the scales. I have been trying to increase my activity level and reduce my unnecessary food intake and it seems it worked.

The airport is outside the city, literally in the middle of the vast Sahelian band that stretches from Mauritania to Somalia/Ethiopia. A few long horn cows were drinking at a puddle on the side of the road, bull carts went by with wood piled high. All the women were wrapped up in polyester or nylon head to feet coverings – pretty close to burkas, except for the covering of the face. When it is 50 degrees Celsius here these coverings must be very unpleasant, but then again, as I had seen from the air during my flight, people can adapt to just about everything, even living in an oven wrapped in polyester.

Driving into town I read the ubiquitous signs that tell the traveler who ‘does good’ here: there were signs about a Good Governance project, another, rather rusted, about ‘Opening Markets for silvo-pastoral products,’ another for ‘Increasing Knowledge for Development,’ and on and on. Some signs were fancy and new, others old, rusted and crooked, probably from projects that have long since ended – as removing the signs is probably not on the ‘close out’ list. The development industry is omnipresent, like in any other beautiful or godforsaken place on the globe. Does it help? I have my doubts that they make much of a difference for those who are supposed to be helped – but it helps me and my family, among others.

Then the stretch became ‘government alley’ with all the regional representations of the government: finance, primature, justice, rural development, agriculture, etc.

We dropped our bags off at the Villa Mourna where we will stay for the next three nights. It is a small guesthouse with 3 inside rooms (for the VIPs like me) and a few rooms outside which, according to my compagnon, one would not want because of the insects that fly in and out. Luckily I was given one of the VIP rooms. For 65 dollars a night (a steal here) I was assigned a small square of a room with weird decorations, a dorm size fridge that doesn’t close, a large creaky bed, a small dorm size desk, a fancy flat TV and a fairly new airco that worked very well. Here the ambient temperature is the same as my body temperature, fine for being but not so great for doing. I slept very well even though the electricity goes out regularly but the guesthouse has ‘un groupe electrogene.’

One of our team grew up here and disappeared at the end of the day to visit family and friends. I joined the program manager who is from Algeria. Earlier in the day we had ordered one of my favorite Senegalese dishes that can be had all over West Africa, Poulet Yassa, chicken in a lemon-onion sauce. It was promptly served at 7PM on the small covered porch of the guesthouse, under the watchful eye of a large flickering TV.  The program featured a documentary about Palestinian Beer (‘Make beer not war’) that was being showcased, and visibly enjoyed by hundreds at an Oktoberfest somewhere in the Middle East. Imagine that!