Sylvia's Journal

Compared to the birthday breakfast I would have had at home, this one here in Man was a bit below the grade, a quarter limp baguette, a vache qui rit triangle and a Lipton teabag dipped in warm water served by a surly waitress. But a week from now I will make up, no doubt, with a spectacular replay.

On the second day of the workshop the group struggled to formulate a measurable result related to better coordination. Not surprisingly, people came up with more meetings and more people at meetings. We pushed for better and more creative results, such as setting up local structures to improve emergency preparedness, but the general attitude is one of victim – we are low on the country’s political and economic ladder and we never get enough money.

People don’t like it when I push them to be more creative and become agent rather victim – this is after all a leadership development program. There is some comfort in being able to decline responsibility and blame others for problems.

This may all seem very theoretical from a distance but yesterday a young woman, secretary of the regional health director whose district director is with us, died in the region’s referral hospital after childbirth. She leaves behind her newborn and two small children. Everyone is very upset about this (though they also remark this happens a lot – as one could see in the maternal mortality statistics).  It seems that the handovers were not done well. When people act as individual professionals and are looking only at their own responsibilities when their task is done, this is what happens. Although lack of trained personnel is sometimes a cause for such tragedies, at this hospital there were enough trained personnel. Heartbreaking, over and over again.

I sometimes think that working in teams, taking on a collective responsibility for outcomes, and willingness to shoulder blame is the biggest challenge in countries where people either have lived in constant fear of getting lost in the crowd of anonymous poverty or are still close enough to be worried. It’s puzzling as I am dealing generally with the educated upper middle classes.

When I challenge the constant coming and going of people holding their telephone in front of them as if it pulls them out of the room, I am told these are urgencies. I count. “You had 10 urgencies today?” (this is not a doctor on duty). “Oui, it is my boss asking for information.” “Can’t you ask your boss to leave a message and you will call back during break time?” They look at me in shock. What, ‘contredire le chef?” Culture and poverty…it is going to be a long journey.

In my profession it helps to be an extrovert. Usually I am energized  by people who are learning, or eager to work together for a common goal.  But today, during the break, I went upstairs to my room and made my own cup of Nescafe rather than standing in line for exactly the same thing, and since I am not eating any of the stuff that is served at break time (all contains processed sugar) why bother?  Maybe it is because I am tired of having one event after another and being surrounded by people all the time. Or maybe it is because I am getting to be more introverted as I am getting older. Tomorrow I will be a little older.

At lunch time we had a heated discussions – I have heard the arguments over and over. They go something like this:

Me: “Why are there no women in any of your teams?” At first they joked. “We did this express.” When I took their response serious, they became more serious: “Women don’t want to work in this part of the country.” “Why,” I asked. “Because of the crisis (=the contested presidential elections four years ago that dragged Cote d’Ivoire into a nasty civil war). “But that was many years ago,” I said.

We went a little deeper. “They don’t have the right credentials.” “Why,” I asked (why is a great word in my work).  “Because they are nurses and midwives (at least in the health sector).” Me: “There are no women doctors?” At our table is a female departmental director (a doctor). She and a representative of an international NGO contest what the men are saying. We ended up with this: “This is how things are ‘chez nous’.”

Me: “You are willing to put a doctor at the head of a structure? Especially if this person (usually a man in most countries) knows nothing about management or leadership, or for that matter good governance? And, therefore does a lousy job such as depressing morale, being a poor planner, not understanding teamwork or delegation at best or being toxic  at worst? Someone who wastes resources (including such highly valuable resources as human energy and goodwill)? You prefer doing that (failure nearly guaranteed) rather than considering putting someone in charge who has demonstrated her management and leadership capacities but who isn’t a doctor?” “Yes” they say, “because a nurse or midwife could not possibly supervise a doctor!” There you have it. Checkmate!

One of my favorite sayings these days is that we tend to generate most of our own problems. Sometimes people get very angry when I say that, but I ask them to consider the practical consequences of accepting this thesis: if you agree then you can do something about your problems. If you don’t accept it there is not much you can do, and you will have to live with all these problems of today and all those in the future. The latter are the complainers – I have met too many of them.

What our leadership development program does is reduce that number quite a bit – our current facilitators are proof. They have started to question a lot more than they did before and in doing so they become change agents. We are working on a critical mass of questioners and critical thinkers, though this will probably not happen in my lifetime.

The passport has surfaced and I should have it in my hands when I board the flight for Addis. Miracles happen and DHL sometimes messes up.

Today we distributed the tasks for the three day workshop that starts tomorrow. I will do very little as I have handed over the baton to the team from Cote d’Ivoire, a mix of MSH staff and ministry of health staff. That was my job and it is nearly done. There were some misaligned expectations of the local staff, our rookie facilitators who inquired about per diem and facilitation fees, a manifestation of the disease we have created called ‘perdiemitis.’ I invoked good governance by saying if there were written rules about that on government letterhead we would gladly pay. Of course no one can produce such a document.

We wrestled with French translations of several words that were invented in Anglophone cultures. Every country and every French speaker seem to have his or her ideas about which French word best represents these essentially untranslatable concepts. We use Leadership and Management instead of Direction and Gestion – there are nuances that get lost in translation. Try to translate stewardship!  We are having endless conversations about this.

The whole notion of andragogy is still alien to people. They have received a classic French education that starts with definitions. One of my new trainees was wondering why we are asking all the questions to participants, like this one “think of a time when you worked in a great and productive team? What made it great?” Luckily one of the people I trained a year and a half ago, the cohort that is now taking my place, explained patiently that it is all about discovery of what knowledge we already have inside us. Yeah!

In the meantime I am counting the days to leave this hotel, have a good massage and a pedicure. This will happen in Addis. I looked up the hotel we will stay in and it has a picture of two Ethiopian beauties smiling in their white towels in the hotel spa. Here, the closed I come to spa is the wrapping on the tiny guest soaps “Spa, les fleurs du coton.”

The hotel owner is apparently some sort of priest or evangelical on Sundays. He showed up in flowing white robes when we settled into our conference room last Sunday. Seeing him in his flowing robes reminded me of the chapter in the brilliant Congo book about ‘la bière et la prière. On Monday he was dressed in ordinary clothes with a ladies handbag crossed over his chest like a conductor, except conductors don’t have ladies handbags. In it is a calculator and probably money. He spends a lot of time calculating.

He doesn’t seem to take his management duties very serious. This morning he sat down in the restaurant watching TV while the curtain rail (including curtains) on one side of room had collapsed onto a couch but he didn’t seem to notice. He doesn’t seem to be in the least concerned about his surly staff, the state of the kitchen, the lax security (regarding personal possessions, not terrorists) and the quality of the breakfast.’

The prefect who came to open our alignment meeting told me it was his third opening of the day. I asked him what else was going on in town. There was a UNICEF meeting to teach the gendarmerie who to deal with kids that had committed (presumably petty) crimes. I was glad to hear. Apparently they treat these kids now in a way that isn’t very nice.

The second workshop he opened was about gender. He told me that men beat their wives and this was a bad thing (I agreed). A research study conducted in the surrounding countryside had revealed that some 42% of the men interviewed (he didn’t know the sample size) beat their wives regularly. “Why, I asked?” “It’s cultural,” was his response. To my astonishment he then added that 48% of the women wanted to be beaten by the husbands. “Why?” I asked again. “It’s cultural.” The percentages indicate that 6% of the women want to be beaten but aren’t. I would love to see this study.

In between my work I am chasing my second passport that, according to the DHL tracker, arrived at its destination (our Abidjan office) last Monday. Proof of this, also available on the internet is that a certain Mariama Coulibaly signed for it, even though the package wasn’t addressed to her. As it turns out there is no Mariama Coulibaly in our office and so we are wondering where my passport went and who this mysterious Mariama is. It is not a minor thing, losing one’s passport, as there is a thriving trade in American passports. On top of that, it contains my entry visa for my next stop, Addis, as the visa in the passport I traveled on sofar expired last Monday – the same day my second passport landed in Abidjan.

I have missed the entire month of November in the US. When I left there were still leaves on the trees and it was decidedly not winter. There had been no serious frost and we were still harvesting. I understand all that is now over.

Saffi has added this month that I missed to her life and is now 4 months old. She can now do things she could not do when I last saw her, such as pushing up on her arms.

I am nearing the end of my third assignment, the longest of them all. When I leave on Friday the team will be on its own. I have no worries or doubts about that. Today they ran the senior alignment meeting with great skill and confidence, with me coaching from the sidelines except for the two sessions that are most difficult to facilitate, especially with debate-happy French speakers (la francophonie). I have learned over the years how to handle this and actually get quite a kick out of it, but, unprepared novices can easily drown in the cacophony of voices and opinions and lose the thread and much time.

I repeated the exercise we did last week, asking what their secret was about keeping Ebola out. This time we had a much more mixed audience, some doctors but also several men in uniform (gendarmerie, the army), veterinarians, the prefect which is the highest representative of the government (somewhat like a governor), members of the regional council, the mayor’s office, animal husbandry people and the regional reference hospital, including the focal point for Ebola. Yet, they came up with exactly the same reasons as the 30 health folks did last week, giving the data some more oomph. I daresay I now know what allowed them to keep Ebola outside their borders: political will, mass education and mobilization, logistical, technical and financial support that allowed them to put all the required equipment in place, training and supervision of the various actors in health and other sectors, including health providers at the community level, coordination mechanisms that actually work and surveillance.

I had the group create a shared vision after a guided imagery followed by drawings. After the initial indignant outcry (‘we can’t do this!’) they all set too work with great vigor and under loud laughter. It was serious play because Ebola is nothing to joke about.

I did notice that everyone shakes hands again – old habits die hard. When I elbowed the prefect he told me bare elbows was still not good enough and we rubbed our covered shoulders.

Everyone thought Ebola had disappeared. The new alert from Liberia (and the ongoing alerts from Guinea) means they have to reconsider such behaviors like shaking hands again. A sick person from Guinea was just returned at the border. The threat is real and nearby; half the population has relatives across the border.

The hunting and eating of bush meat is still being enforced and those who made their living doing the hunting and selling have been given a new trade, charcoal, thanks to the quick action of one of the ministries that had figured out that forbidding a trade and not replacing it so people can continue to feed their families will only lead to cheating. People have been put in jail for ignoring orders from up high. It is a matter of life and death and so they take everything quite serious.

After hours, at 5PM every Monday, the coordination committee meets for exactly one and a half hours. It starts exactly on time when the prefect enters. The actions from last week are read and everyone present is held accountable. Only a very good excuse is acceptable I am told. During the height of the outbreak next door, these meetings took place daily.

I was the first for breakfast this morning, testing how well prepared the kitchen was for having some 30 people show up every morning this week.  As there was no one in the restaurant I ventured into the kitchen. What I saw there was rather disgusting, and once again I am amazed they were able to keep Ebola out. The place was filthy with plates from last night’s dinner heaped up and general chaos. I swore not to eat anything that was cooked in there and this morning I declined the omelet. It is going to be a week of limp baguettes and tea. The luxury will be the small Vache Qui Rit triangles that I will buy myself. It is a bleak prospect but it will all be over by Friday.

What is also bleak is the news on France 24 with all these images of serpentine wire, guns, explosions, blood and crying women. And then there are the documentaries about climate refugees; this morning was about villagers in Bangladesh whose livelihood has been wiped out and who are now squatting in the slums of Bangladesh. I watch more TV during my trips than at home and it is a sapping experience.

Bleak is also the large mirrored bar cabinet in the restaurant that doubles as bar at night. It could hold 40 bottles but there are only three, whisky, gin  and something else, that speaks of loneliness and its consequences.

I am utterly aware of the catabolic energy that pervades just about everything and I am determined to turn it around, at least with the people I can influence this week.

This morning we went to the Cascades de Man. It is the touristic attraction of the region. People go here just for the waterfalls. It is the end of the dry season and so the waterfalls were not as spectacular as they are during the rainy season, but nice enough. The road there and the waterfall ‘amenagements’ as the French call it have added an element of ugliness to what is otherwise beautiful mother nature. The road to the entrance, where the ticket man sits, is hardly navigable in the current dry season. I can imagine that during mud season only 4×4 can get there, and not easily.

Once in the area of the waterfalls the tourists are helped by a steep set of uneven steps and a railing. That was helpful. Once down in the waterfall valley large slabs of concrete and preformed benches and platforms have been put in place willy-nilly without any sense of esthetics. They are practical as you don’t have to jump across rocks but also an eyesore. A small mildewed pavilion puts the finishing touches on the “amenagement.” It is run down, fungus on the walls, garbage – it will be fixed the guide told us. He is not paid by the ministry of tourism and lives on tips. I wondered whether the man who collected our entry fee (200 CFA which is less than 50 cents) is an employee or also a volunteer, and if the latter, whether he can keep the change.

There is a bridge made from vines that the villagers made in order to cross the cascades. It is in rather poor repair and fortified with man-made ropes. Our guide showed off, walking a few meters onto the bridge, saying that we probably couldn’t do it but he was and experienced guide. “Huh,” I puffed, “I can do this,” and we were all allowed to take a few steps on the wobbly rope bridge. Clearly, there are no lawyers here who make the rules. It is not that difficult when one has no baggage but I was wondering about women having kids on their backs and wares on their heads when a deadly force races by several meters below.

We returned to the concrete slabs and made our way to the big cascade. A large pool in front served as a self-cleaning swimming pool. Two small boys in their underwear were having a great time. Higher up the cascade formed a series of plateaus, nooks and crannies which enticed many adults to partially disrobe and take a shower while posing for their friends.

There is a steep path to the top of the cascade which we declined to take – our shoes were the wrong footwear and it was too hot. We also declined the two hour walk up to the ‘dents de Man,’ two large boulders that could have been the teeth of a giant.

On our return we went back to La Paille, the Senegalese restaurant where we are taking all our meals outside work hours. Today the waitress was rather sullen, eating a banana in a rather seductive way while taking orders. It looked as if taking an order was a tremendous effort on her part, as if she’d rather had the customers go away.  But she had an amazing hairdo and I was allowed to take a picture. It is the only smile she gave us.

I ordered again a Cieboudien (also affectionately called a Tjep), Senegal’s famous rice and fish dish, but with chicken. That was a mistakes as the chicken must have been of the elderly kind – little meat and sinewy.

Back in the hotel we went to check out the conference room and found the trainers of a workshop that had just finished. The topic, according to the banner with logos of the International Rescue Committee, the French, the EU and the Ministry of Health indicated that the workshop had been on the “Renforcement du système de santé.”  Interesting, I though, we are doing the same, but we are doing it with American money; and as I have learned along the way, usually the French and American development aid groups work in parallel without much contact and sometimes even in direct competition.

Here we are, working on intersectoral coordination when coordination within the health sector is hardly happening.  We ended up chatting with the organizers and discovered that they had been training midwives in safe motherhood and delivery practices. That too counts as health systems strengthening (everything counts as health systems strengthening – abbreviated as HSS- these days). The representative of the International rescue Committee mentioned she was not invited to our event so we quickly extended an invitation as she is clearly another critical player in the HSS dance.

Two things are abundant here: prostitutes and insecticide.  The former are recognizable by their very (very) tight and very (very) short dresses that leave nothing to the imagination and the latter by the constant affront to the senses and (it works!) the dead bugs in the shower. I don’t think anyone reads the labels in order to understand that these two practices are not good for anyone’s health. On the other hand, I am heartened to hear (on TV France) all the climate-related inventions made by young and not so young people around the world and in particular in developing countries to make everyone’s life better, humans, fauna and flora.

The hotel we stay in now is a little simpler than the previous one. If that one was half a star, this one is zero star. Some things are better, others worse: the airco makes less noise, the room is larger, the bed is larger, the door lock is hardly secure, the shower works until my neighbor starts to shower, and the water supply is on and off, as is the internet connection.

Breakfast this morning was rather chaotic and of the basic kind: a section from a limp baguette, an omelette and a Lipton teabag dipped in water that boiled awhile ago. In the other hotel we had a luxury breakfast: juice, croissants or pain au chocolat (both rather limp and a bit too sweet for my taste), jam, butter and a vache qui rit wedge in addition to the bread and omelette.  The fruits we added ourselves (papaya, watermelon, pineapple). When out in the country in most developing countries we stay in hotels that usually don’t cater to foreigners with expense accounts and so the lodgings are rather basic and payment straightforward: in cash.

I left the previous hotel without paying my bill because, contrary to what they told me on check-in, they don’t take credit cards. They would take Euros but I had none. “We don’t take dollars!” said the receptionist and her helper who was dressed in a lacy Victorian dress. “Why not?” I asked. “Because the Euro doesn’t fluctuate but the dollar does.” I offered them a really advantageous exchange rate but that didn’t work. In the end our accountant picked up the bill while I was cruising around town looking for an ATM.

What I had not counted on was that it was the end of the month. Everyone who receives money in the bank at the end of the month, not just from Man but from wide and far had come to Man, some spending their last 300 CFA on a taxi ride. People sleep in front of the ATM. When we made a tour of the city around 8:30 AM the lines were at least 100 meters; the ATMs without lines were already empty. A kind of monthly black Friday. We checked out all the ATMs in Man to no avail.

Last night we tried again and found the lines short, about 15 people waiting in a more or less orderly line, all men. The first 7 were crammed into the air-conditioned portal of the machine itself, and the rest waiting outside. An man in police uniform bypassed us all saying he had urgent business. I hassled him so much that he made mistakes with his password, exiting mumbling ‘zero, zero,’ (everyone laughed). He came back in again through the exit door, once again bypassing everyone. No one seemed to mind very much – they are used to abuse of authority according to my colleague F. My hassling distracted him (guilty conscience no doubt) and it took three tries before he had his money (and very little of it, about 15 dollars worth of CFA). It was a (very small) taste of obnoxious behavior of people in uniforms.

Of course it is nothing compared to what I read in the Congo book that I have now nearly finished. There I wouldn’t have dared to contradict a person in uniform as those folks are dangerous, even if they don’t wear a uniform. I am learning about despicable behavior of Heineken in the DRC that makes we not ever want to drink a Heineken again.

We finished our training and split up in three teams, one staying here (with me), one going north, close to the Malian border and one going south – all three regions bordering either Liberia, Guinea or both. Each team consists of staff from the central ministry of health, from MSH/Abidjan, from our staff in the region and local health officials.

This morning they practiced sessions they will be doing next week and everyone gave feedback and everyone learned a few tricks of the trade or something about themselves. There was even talk of leaving one’s ego home – not raised by me, though I often think this. Many of the participants are doctors in senior positions and being vulnerable is not something they are used to – but most people took this challenge in stride. I saw a few people transform in front of my eyes.

Tomorrow we will move to another hotel since UNDP reserved all the rooms many months ago. It will probably be one star less (which means 0 stars) and I have to pack my suitcase for the 6^th time in 4 weeks.

For our last night together the two women I have been dining with at the hotel each night, took me out to eat “poisson braisé”. The fish we had at our hotel all week was OK, though not exceptional. The street fish we got tonight was exceptional.

The driver took us through the streets of Man to a main drag where all the women lined up with their fish. The hotel had cooked sweet potatoes for us and gave us a plate to take to wherever we were going. I can’t quite get over this: my colleagues buy food and then give it to the hotel to cook and they serve us and don’t charge a penny. My colleagues are not in the last shy about this. “Why not?” they ask, “it’s cheaper when you buy the food outside the hotel.” Well of course, I think, but that’s how hotels work. But the restaurant manager happily takes the pineapple, the papayas, the sweet potatoes and cooks or cuts them and serves them to us without giving us a bill. It appears completely OK.

Maybe this is the same surprise that Africans have when they come to the US and see us waiting for a red stoplight when there is no other car in sight. Or when we get a ticket mailed to our home and we obediently put a check in an envelope and pay our fine. Many Africans find this bizarre.

We ordered our fish and then waited for it to be served for an hour which gave me plenty of time to observe the scene around me.

A kiosk across the street read “verywhere you go,” which I thought would be a good title for a book. There were kids the size of Faro (probably older), shoeless and unsupervised, and kids the size of Saffi riding on their mother’s back; there were young girls waiting for something to happen, just standing there and older boys hanging out. There were “salariés” as employees are called here, eating with colleagues, probably because their wives or mothers live far away and so they fend for themselves and eat out for a few dollars. There were “vendeuses” and little boys selling stuff, going from table to table. The boy sold packs of paper napkins – a captive audience that eats with its hands the greasy fish and sauces. The vendeuse sold deodorant. She was young and beautiful and at every table with only men she was asked for a demonstration and everyone got to smell the pink or white or yellow sticks, made jokes, with an occasional buyer. Her charm got her to show her wares. I saw a great deal of poverty and the desperate jobs that come with it.

The salaried people (including us) all had at least one if not more cellphones. Many have them in their hands – few clothes have pockets. Everyone who was sitting at a table was focused on their device. Even couples, the one next to us ordering a large coco cola and a bottle wine sat silently side by side looking at their phones. My table mates, during the long waiting time, spent a good chunk of that time playing games or talking on their phones. This cellphone disease that has cut out conversation has spread around the world, wherever I go.

Although participating in the Thanksgiving celebration on Skype doesn’t satisfy all the senses (smell, taste and touch), it did satisfy some (sound and sight). I connected three times during the day, following the various preparations from early morning (nothing on the stove at all) to mid-day (giant turkey in oven), to ‘nearly there.’ We remembered last year when the electricity went out and we huddled around the stove melting the snow for tea, coffee and other liquids. This time things were easier.

I got to show my face to Saffi who doesn’t quite understand the concept of ‘Oma,’ and see Faro being a bit too helpful in bringing in an egg from the chicken coop, egg dripping on his hand. An information session on the fragility of eggs is clearly in order.

I learned more about the various creative endeavours of the members of my family: Sita has already made ceramic mugs, Tessa showed the ring she has made and Axel is making art on silk. Sita asked me what I wanted to learn to do, other than knitting and embroidery. I had to think a bit. Woodworking I finally said, something I did two decades ago at the local vocational school, but now I travel to much to take scheduled courses. I made a coat rack, fixed a set of drawers, made a clothes valet for Axel and saw horses – all in good use still. More than 5 decades ago I learned woodworking in France during a summer camp. I made a small stool, turned a salad bowl and egg cups. I love the feel of wood and see a rough piece of wood transformed into something of beauty. Actually, I like transformations, period. Even here, in five days I saw some transformations, good ones.

I can’t wait to be back now and am counting the days – 14 days to be exact, and two more assignments remaining. It’s been a great trip so far but I don’t think I am going to make it a habit to be away for 6 weeks, unless Axel comes along.