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.