Sylvia's Journal

The people who have come to this workshop are quite diverse, as compared to the typical workshops we organize for health professionals.  We have representatives from various community organizations, managers and chief medical officers from hospitals and representatives from the local administration (the prefecture) – recognizable by their khaki uniforms.

We talk a lot about ‘engaging the community’ but when you have barely literate women sitting side by side the doctors you quickly see what the challenge is. I can now imagine what some of those COGES meetings are like. Even the body language of those concerned speaks volumes.

In the groups, 3 or 4 people sitting around the computer brought by the hospital manager or doctor – the local administration and community group representatives have no computers – one can see the dynamics just by noticing the physics: the women with their chair slightly pushed back, sometimes even in second rows, some leaning back; the men in khaki – some leaning back, some on their phones while several of the women in khaki are bent forward and appear quite engaged; and then the hospital folks at their computers, they are at the wheel – I suspect this represents reality.

Many of the hospital people, and some men in khaki, had already gone through our leadership program and knew the process, the way we work. They are by and large better educated than the community reps.

But when the district teams had selected their challenge it included nearly always ‘the problem of the women’ as it is sometimes referred to. This meant that the men had to listen to the women to understand the issues – mostly that they were appointed to the committee without any orientation or training in how to function well on a committee.

There is much implicit bias. Even those supposedly ‘enlightened’ showed this implicit bias by their words and behaviors.  You can ask ‘why?’ in two different ways, expressed by two similar sounding but entirely different words: inquisition and inquiry. Yet, even if the ideal of equality is still a faraway goal in this country, I see movement. In this workshop one in four participants is a woman. This is progress. And of those not representing women’s group, many are women in khaki, representing the power of the state at the local level. That too is progress.

What is it with bathtub installers in the hotels in the provinces here? During a previous visit in another town, the faucet was installed in such a way that it didn’t reach all the way into the tub and splashed all over the bathroom when inadvertently turned on.

Now, in my otherwise quite pleasant and spacious room, the bathtub is installed in such a way that they had to hack an edge out of the wall to slide in the tub and the reclining side of the tub is placed right under the faucet.

I wonder when I see such things what happened prior to the installation. I imagine there was no diagram and the installers themselves may have never sat in a tub like that. So how would they know that the side that slopes down at an angle is to be on the opposite side of the faucet?

But then I wonder, wasn’t there a supervisor or a contractor who inspects the work? Again I imagine the supervisor checking the plumbers’ work. Did they not notice? Do they themselves have no familiarity with modern tubs? Did they never check or did they notice and realized that it would be too much re-work?

The puzzle for me is that some workmanship is excellent and elegant, like the rosettes on the ceiling, and others is sloppy, like the three doors of my closets that don’t close and can’t even be locked despite the keys dangling from useless locks. Again, who was checking and if so, why weren’t those things fixed? I can’t help but think that these symptoms reveal much about why Africa keeps needing help, despite the billions of dollars poured into the continent.

Our hotel is the strangest structure. I constantly lose my way as I walk from our meeting room to restaurant. There are narrows passages and uneven levels, floor one on the left is at a different level than floor one on the right. There are meeting rooms everywhere, and workshops going on in some of them.

As for the structure itself, it is as if someone dropped a bunch of concrete pillars and walls from the heavens, covered everything with a sticky substance and then threw a collection of tiles of every color and size over the result.  Or, and this is more likely, it was a small hotel that discovered there was money in hosting training events, and kept adding halls. Everywhere are citations or bible verses in haut relief inscribed on the walls. I live under ‘God will protect you.’

It is definitely not a structure that is friendly to people with physical disabilities. And yet we have one such a person in the group. He is a hospital manager who walks with great difficulty using two crutches, one leg useless for walking. Since I have been working with ICRC I am very much aware how rarely buildings are designed to accommodate people with physical disabilities. And this makes it hard for some groups to participate. But participate he does, climbing all the crooked stairs, three levels up clutching his crutches and his briefcase. We started to talk about my work with ICRC and the people I worked with, what I learned from that. He was pleased. I promised to introduce him to the chief of the Paralympic Committee in Niger.

The first night I discovered the restaurant where we are served breakfast was dark. I returned to my room – everyone had disappeared someplace. I lived that night on a banana and a bag of almonds. The next morning I found out there was another restaurant at the entrance to the hotel which I had not noticed before. I went downstairs and sat down – the TVs were, as usual, showing football matches and one man was watching. It quickly became clear that it was not the kind of restaurant where one sits down and is served, even though it looked like it was. I should have ordered food at lunch time and then it would be served in my room. If I did not want to eat in my room I would have sat there for at least an hour, all by myself, and watch football or some mother sketchy program on TV. I thought I had ordered something simple, grilled chicken and a tomato salad. One hour and a half later the food was served in my room.

There was no time to rest. After the short flight (from Amsterdam to Paris), a stop in Paris and the connecting flight to Abidjan I arrived in my hotel late Sunday evening. I was able to negotiate a chef salad with the two remaining servers in the empty restaurant where the lights had already dimmed. I think they were willing to serve me because there were two giant screens with football (soccer) matches going on. They watched while I ate the leftover meats and cheeses from breakfast and lunch served on a bed of iceberg lettuce. The best part of the meal was the mustard mayonnaise, which I ate right out of the bowl.

I was picked up at 6:30AM by our driver to take me to a regional capital some 100 KM to the north of Abidjan, to arrive just in time for the training of trainers’ workshop that would start at 8:30AM. Getting out of the city at this time of the day requires navigating endless traffic jams. We arrived about 8:30AM and found the team at breakfast.

Luckily I knew most of the 12 or so people in the group. I had trained some of them several years ago and watched them perform earlier this year, to my great delight. I had effectively passed the baton, at least to some of them.

I had rearranged the two-day program earlier to consist mostly of un-programmed time so that we could practice simulate parts of the governance workshop and practice. This turned out to be good intuition and the facilitators grew in confidence in front of my eyes.

Our Cote d’Ivoire project team always arranges for a brief training of trainers before any event. They have done this for years, more so than in any other place I have worked. As a result there is now a considerable pool of confident and experienced facilitators who do the work I used to do. Now I limit myself to introducing new techniques and methodologies which they absorb like sponges.

The event for which we were preparing was a governance workshop for representatives of Community Management structures (COGES) tasked with the oversight of the district hospitals. The adoption of practices of good governance is something of great importance here. The challenge is to reduce the gap between words and deeds when it comes to good governance. The gap is big.

I spent three days with malaria experts from Africa and one team from Nepal, our own MSH advisors who brought along their government counterparts.  It was truly a united nations. United about the goal of eradicating malaria and about 20 different nations represented. In addition there were a few representatives from our competitors who, in this case, are also our collaborators. They will be taking the baton when our project that has provided the funding so far, ends in September. This is to make sure the transition doesn’t hurt the women and children who need to be treated or protected from malaria. It is an act of synergy and collaboration that is not all that frequent (outside partnering on a bid) in an otherwise very competitive field.

For three days we did not talk about malaria, or very little, but rather focused on the human harmony or disharmony that helps or hinders the work that needs to be done. This is of course entirely in line with the original founding philosophy of MSH, which was all about the unnecessary suffering and death as a result of poor management and leadership (and governance which was added later).

Our doctor experts, and their counterparts, are both causing and suffering the consequences of not understanding human dynamics. They know the theory and focus all of their attention on what others are doing wrong. It is a familiar refrain: the politicians, the senior leaders, the donors, the villagers, the healthcare providers…one or the other or all are doing things entirely wrong and so they need to be put on the right track. There is a lot of preaching and wagging fingers and doing it harder and louder when the hoped for result stay out.

For three days, in this coaching and communication workshop, I exposed them to everything I have learned over the past 7 months about the neuroscience of getting people to work better together, share, expand, appreciate, create a climate of trust, develop, celebrate and include. The term is to ‘up regulate’ those and down regulate the criticizing, the excluding, the judging, the withholding, limiting and dictating.

Although most of the people are doctors, they know little about the brain (little of the little we know about the brain), and so for a change I was the expert. Since the workshop was in English and French, with simultaneous translation, I switched between French and English in order to give one group and then other a break from the very uncomfortable headsets. On the third day I noticed some confused expressions on the faces of the French speakers. We had talked a lot about the limbic system and the amygdala. As I discovered, the word amygdala comes from the Greek word for almond, as the amygdala are almond shaped. But there is another part of the body that is also almond shaped, the tonsils which, in Dutch, German and French uses the same Greek derivative: amandelen, Mandeln and yes, indeed, amygdales.  And so, all the time I had been talking about the amygdala, they were wondering about tonsils. In my coaching course I have learned that ‘words means worlds.’ So very true. I was glad we had cleared that confusion up before everyone went home.