MSF Blog: Chiradzulu part 13

As the data manager on the team, I’ve learned tons about data management, STATA and staff management. But I’m more amazed at the obscure skills I’ve acquired, like 1) having a sixth sense of where the matches are when the power goes out; 2) cooking for a dozen people with two burners and an electric kettle; 3) driving a manual land cruiser with right-hand drive; 4) saying “Thank you” in a half-dozen languages; 5) finding constellations in the southern hemisphere; and perhaps most important 6) letting go of expectations. I’m not quite sure what my expectations were when I arrived. Somehow “saving the world” seemed a bit ambiguous, but was headed in the right direction. Now, after 6 months, I’m thinking I will have gained more than what I have given.

I am more appreciative of the extended family here. Though people may live with their spouse or parents, their financial obligations extend beyond the immediate family. Unemployment is probably over 50% (statistics are an evasive animal here), so when someone is working, they are often supporting people outside their immediate family. If someone asks for help, you just give – not necessarily a lot, but what you can, because you can. This is an area where I have stumbled a lot. I see many men drinking their money away, so am wary to fund such liquid assets. Meanwhile, prices of food have doubled in some areas, and though we expats may not have cookies or yogurt for a week, I don’t know what my national counterparts are sacrificing.

Shops in the region, photo by Pat Carrick

MSF-France has been in Chiradzulu for over 7 years treating patients who are living with HIV. There are about 15 expatriates, and 150 national staff. The expats come here as supervisors or managers, but most with little or no context of understanding Malawi. Even I have been here for 6 months, speak enough Chichewa to get by, but still stumble over many local customs – and I’m very far from understanding what exactly motivates people. In this setting we expats arrive to supervise staff. Some of us, on top of no Malawi-experience, have little or no HIV experience, while our national counterparts have been treating HIV patients for years – in Africa. But we are here to supervise and manage the program. Of course every new expat who is here for a few months wants to feel like they made a difference – that our time during a mission served a purpose – so we look for some new improvement to implement. We bring our expertise from whichever country we are from and impose our great ideas on these people of whom we are guests. Sometimes we don’t bother to ask our staff what they think. After all, we are the expats/experts.
It’s difficult to be a manager, there’s no one to tell you if you’re doing a good job – or if you’re doing a bad one. I wonder how long we expect to supervise? Perhaps what makes it difficult for MSF here is that it’s a long-term program. MSF is used to working in crisis mode which cannot be sustained for long periods of time. But this HIV project has been here for 7 years, and will probably be here for another 7, at least.

Chiradzulu Hospital, photo by Pat Carrick

Maybe what Africa needs from us first is a willingness to understand, only then can we be understood. If you want people to build a ship, you don’t teach them how to chop wood and build sails, you get them to yearn for the sea. (I think a French writer said that.)

We’re learning how to implement water conservation tactics, not because any of us are big Al Gore fans, but because we’re bracing ourselves for the impending water shortage. The guys on the mission have proposed communal showers.

Sandy, from Chiradzulu in Malawi

(Traditional dancers in Chiradzulu during World Aids Day 2006, photo by Pat Carrick)

IN PLACES FRAUGHT with famine, poverty, disease, and war, it’s difficult not to feel as if you aren’t doing enough. Perhaps, rather than trying to solve all the problems, it’s smarter to try and make things just a bit better. It can start with changing ideas.

IT’s CRAZY TO think that centuries of beliefs can be dismissed with an IEC campaign, but ARV’s are having an impact. There’s an MSF video about the HIV project here in Chiradzulu. At the end, it shows a woman, bringing out bottles, canisters and jars, full of herbs, liquids and powders. She is standing on her porch, and dumps each of the containers, one by one, in front of the camera, the whole time explaining how none of the traditional medicines helped her. After she empties the last container, she picks up three white pill bottles and holds them up, declaring that these ARV’s worked when nothing else did. Then she holds out her arms, as if to offer herself for inspection. She proclaims herself fit again; strong enough to collect water, cut wood, harvest maize. She ends by telling the audience that if they are sick, they should get tested, and then get treatment; life can be reclaimed, just look at her. It’s a powerful yet simple message. That’s the best way to dispel myths and superstition. There’s a lot of superstition in Malawi, though it isn’t often talked about. The unknown breeds superstition.

IS IT HUMAN nature to be fearful of the unknown, or is it society that makes us scared? Shouldn’t curiosity be the natural reflex to something we don’t understand? How did fear become the knee-jerk reaction to the unknown? When responding to fear, we tend to hide, fight, runaway, attack, denigrate, demonize. We naturally think that something we are scared of is something bad for us. But if we are always afraid of what we don’t know or understand, then do we presume the unknown is bad for us, or against us? Doesn’t that limit our future, potential and possibilities?

JUST IMAGINE IF we only lived according to what we already knew – that would be like watching reruns over and over. And as much as I love watching season 3 of The Office, I am so looking forward to see what happens in season 4.
Maybe it’s better to embrace the unknown, study it, take it apart and understand it – without judgment.

SOMETIMES I GET irritated when I hear an expat make a quick judgment about someone after a brief encounter, or about our adopted country after a few weeks in the field. It’s not fair and it shuts down any opportunity to learn from each other. If we’re looking to simply put people in boxes – boxes we’ve designed and created from our own biases – we should be ready to sit in one as well.

LIFE IS A discovery, but staying open can be difficult as it requires patience, tolerance, and imagination. Just imagine you don’t know. As soon as you think you know everything, you stop learning. After my first month, our French nurse told me that on a mission you learn a lot, but in the end you learn the most about yourself. I hope I can stay open enough to continue to learn.

I WOULD LIKE to learn how to open a bottle without a bottle opener. Malawians use another bottle, our French logistician uses his lighter, and our administrator from Cote d’Ivoire uses his teeth!

Sandy, Chiradzulu - Malawi

(Photo by Pat Carrick)

MALAWI IS KNOWN  as “the warm heart of Africa,” consequently it’s not surprising that people are friendly and nice. People are very nice in Malawi. So nice, that they’ll never tell you ‘no’ (unless you’re trying to bargain in the marketplace). Instead of disappointing you with a negative response, they’ll typically give you an affirmative. After that the follow through is your own best guess. I suppose it keeps life interesting. Being open and patient and tolerant can help get a more realistic response.

IN THIS SETTING, you can imagine that trying to get my staff to respond during trainings has taken some gentle coaxing. If they were afraid of me, I’d never know it, and if I asked them why, they’d never tell me. Wouldn’t that be a funny picture? Hence I implemented a suggestion box, and wouldn’t you know it, all the suggestions have been anonymously and neatly typed and printed. Some were quite helpful, like requests for cross training on projects, or criteria for selecting a new team member. Others were as innocuous as suggesting to shift bi-weekly meetings to once a month. I guess I should have noticed I wasn’t the only one bored with hearing my own voice. But they’re quite attentive during trainings. We had our first Epidemiology/Data Management exam, and the mean was 81, and everyone passed! I was so proud of them! In a world where money seems to be all-important, I hope I’m instilling that knowledge is power. And anyway, money can always be lost or stolen. Or spent – and quickly. ‘Saving’ doesn’t seem to be a popular concept here.

I WENT INTO town (Blantyre) one Saturday, at the end of the month, and the Friday before I asked my staff if anyone was going to be out shopping. “Nobody goes shopping at the end of the month,” was the reply I received. “There’s no money left.” Last Saturday (beginning of the month) I was out with friends, and the bar was packed. I stupidly commented on how full it was compared to the last time I was out (I’ve only been out twice). “Because it’s the beginning of the month and people have money in their pockets,” was the reply this time

NO, I’M NOT in Kansas anymore. And I’m going to have to learn some communication strategies if I’m going to leave behind any lasting impressions. I used to think the Communication side of public health was “soft science.” Education and awareness campaigns seemed common sense to me. How hard is it to tell people HIV is passed through unsafe sex, thus they have to wear a condom? It seemed logical and simple from my perspective. But from the African perspective, having sex with a condom is like, “eating candy with the wrapper on.” There’s got to be a better way to promote safe sex. I have a new respect for the cadre of Communications folks who are out there trying.

MEANWHILE, THIS CONTINENT is being decimated by AIDS. In Malawi alone, it’s estimated that 90,000 people die every year from AIDS-related diseases. That’s a big chunk of people to lose every year. And it’s not slowing down. It’s also estimated that 1 million people are HIV positive, and that number is growing by 100,000 every year. There’s only 12 million people in this sliver of a country. We have got to figure out how to communicate with Africans that unprotected sex kills. This is a society where it is taboo to speak about sex, yet it happens casually. By providing drugs, we are giving people the chance to live, but if we don’t get the message out on how to stop the spread of HIV, we haven’t given this continent more than just a grace period.

Sandy, from chiradzulu in Malawi

(Photo by Pat Carrick)

I STEPPED IN  a cow pie today. I guess it was bound to happen. I usually pay careful attention to avoid them, but instead of watching where I was stepping, I was telling a child that she shouldn’t practice her English with the phrase, “Give me money.”
 

MY USUAL DIALOGUE with the children on the road is pretty standard, and typical, and redundant. It goes something (or exactly) like this:

 Hello!”
“Hello.”
“How are you?”
“I’m fine, and you?”
“I’m fine. What’s your name?”
“My name is Sandy, what’s yours?”
“My name is…” Precious… Innocent… Blessing… Gift… Witness… Bright… Action… Mountain… Snowflakes… Brain… Reverend.”

TO BE TRUTHFUL, those are the most unusual boys names I’ve heard, but it’s usually the girls who talk to me. Their names are the Biblical ones you might expect – Rebecca, Hannah, Deborah, Lydia. I’m getting better at recognizing them since I usually walk the same path in the mornings and evenings. My favorite is a little boy who is just learning English, and hasn’t yet mastered the order of the dialogue. He goes straight from “Hello!” to “I’m fine.” His eyes are so big and he’s always smiling that I laugh every time, and simply reply, “I’m fine too.”
Or maybe his name is Fine? Anyway, the kids are always happy to see me – and they help with my Chechewa (local language). They are more forgiving with my Chechewa than my coworkers.

PERHAPS FORGIVENES IS  the first step to innerpeace. (That’s a big transitional jump, but if you do yoga everyday, you find something meaningful in everything.) I’ve been thinking about innerpeace lately because many of my teammates are regularly stressed. If forgiveness is the way to peace, maybe – before you can truly forgive others – you have to forgive yourself first. Perhaps people are so stressed on missions because they have very high expectations for themselves, which makes it very difficult to be okay with making a mistake.

I THINK OUR Field Coordinators have the toughest job. The buck stops with them, so they have to make sure everything is in place. If something is out of alignment, it’s their job to make it right. It’s a tough position to be in. And if you’re expecting the best from your staff, you expect no less from yourself.  After all, we’ve left our families, friends and comfort zones to do what we think is making a difference. I have received numerous emails from family and friends reminding me that at least I am doing something positive in the world. But I don’t think you have to travel to Africa to have an impact. The simple act of treating others with dignity and respect, whether they are sick, poor, healthy or rich – those with a high status and those without – this simple act of treating each other the way we want to be treated can have a profound effect.

BUT THEN IT begins with ourselves. Sometimes…oftentimes we are so hard on ourselves for making a mistake that it becomes difficult for us to be okay when others make mistakes. In the end, we are all doing what we think is right. It’s our motivations that can be different. Egos get in the way, as does pride. Emotions can sometimes steal away our sense of perspective. But when we remember that we are all sharing this planet – that we are all human in our imperfections – then it’s okay. Because in the end, we are all here for each other. Otherwise, what’s the point?

Sandy, Chiradzulu

MSF Blog: Chiradzulu, part 6 (photo by Pat Carrick)

MSF-FRANCE IS getting ready for their annual General Assembly in June. I’m still learning about how MSF operates, but the more I understand, the more impressed I am. Everyone who works for MSF, national staff and expatriates, has an opportunity to belong to the Association. Association members elect a Board of Directors and then a President is elected from the Board. That all sounds standard, but what’s impressive is that MSF really attempts to reach into the field and get feedback from its staff on how it operates. It does this with Field Associative Debates, or FADs. (We had two such meetings on Saturdays in the past month and so I haven’t had much time to write – thus the delay in this blog.) But what’s most impressive is that the whole system is set up so that decisions made in Paris are based on input and feedback from people on the ground – in the field. It’s essentially an international democracy, a club of do-gooders. Of course, this is the theory, and I’m not sure how well the whole thing works in practice, but at least the structure is there.
OUR SECOND FAD was in Thyolo (where MSF-Belgium is working), a beautiful place that reminds me of Ooty in southern India. It’s full of tea estates and you can see miles of rolling green hills. In between the fields of green tea plants were red roads of dirt that cut through the estates. If they were paved in yellow bricks I could have been Dorothy heading for Emerald City. In the distance was a hazy, but still magnificent, Mulanje Mountain. Malawi is truly a beautiful and blessed place, and every day I feel lucky to be here.
I’VE BEEN HERE in the field for two months now, and our team is really starting to feel like a family to me. Though I still miss my friends and family back home (and those scattered through all parts of the world), there are many things that I don’t miss. I don’t miss waking up on the weekend and still feeling stressed because I have so much to do and wish I had a weekend from my weekend. I don’t miss my cell phone. I don’t miss searching for news and instead finding the latest antics of some celebrity. And I definitely don’t miss eating dinner alone in my kitchen.
BUT AFTER JUST two months here in Malawi, I can already tell that when I leave, there are many things I will miss. I will miss having “climb a mountain” on my to-do list for Sunday. I will miss getting the latest news from fresh magazines that arrive with visitors. I will definitely miss the family feasts of French cheese, Belgian chocolates, and South African wines that arrive with new team members. But most especially I will miss the easy laughter and smiling faces of Chiradzulu.

AND HAVE I mentioned my magic hamper and magic kitchen sink? They’re brilliant! You place dirty clothes in the hamper in the evening, and the next evening your clothes are clean and pressed. The kitchen sink works much the same way on dirty dishes. Oh yes, I will miss these items too and wish I could bring them back to America with me. But I have a feeling they wouldn’t work anymore, as they seem to be nonfunctional on the weekends.
Sandy, Malawi

THE BIGGEST FEAR a first-mission MSFer has is that there will be no one at the airport when you arrive. Fortunately that wasn’t the case for me as I was greeted by a throng of helpful porters and one taxi driver holding a sign with the all too familiar red running man that was to become the symbol of my new family.Going on a mission with MSF is certainly an adventure, but also requires a leap of faith. And it starts before you even get a plane ticket. I must have taken half a dozen vaccinations along with some malaria prophylaxis the month before I left. That’s a lot of drugs in a short time for someone whose stock of Tylenol expired a year ago. But with my 20kg bag packed, I headed for Paris.

THE MSF OFFICE in Paris is somewhat like a command center in the middle of a railway station. There are piles of luggage at the front desk, intermittent pages on the intercom, a camera crew interviewing someone, and all kinds of people rushing about. It’s difficult to tell who really belongs there besides the receptionist. But if you get stuck with a late night departure out of Paris to your mission, there’s a quiet lounge on the fifth floor where you can crash on the couch or watch the last bit of television that you will see for a long time.

IT IS CUSTOMARY and essential for making friends – to bring some goodies to share. So it’s best not to carry too much as you’ll have to stop at the Duty Free at your last international airport to buy wine, cheese, and as much chocolate as will fit in your carry on luggage. Trust me on this one.My own arrival into Malawi was uneventful. After a quick briefing with the coordination team, I was off to the field: Chiradzulu. I’m very lucky that my first mission is in Malawi, because it is a beautiful country. In Chiradzulu there are mountains in every direction, and it’s hard not to pause at sunset, wherever you are, to take it all in. The view from the hospital is an expanse of green lying at the base of Chiradzulu Mountain, which serves as the backdrop to this gorgeous mission location. It is currently the trailing end of rainy season, and sometimes clouds will sit atop Chiradzulu Mountain and slowly roll down like bellows of smoke from a chimney. The smiles on people’s faces are always bright and inviting, which gives credence to Malawi’s reputation for being “the warm heart of Africa.”

UPON MY ARRIVAL, my first task was to decide in which house to live. It’s a big team in Chiradzulu, a baker’s dozen of Europeans, North Americans, and Africans. House one has most of the French speakers, which means evenings of cigarette smoke on the porch. But it also has a phone line and hot water, not to mention the logistician (someone you always want on your good side – I brought him his own bottle of wine). House two has a spectacular view, a phone line, but no hot water and it’s a bit of a trek if you wanted to walk (which seems like too much of a bother after a long day). House three also has a spectacular view, the kitchen (which can be dangerous if you eat when bored or stressed), hot water, but no phone line. Against the advice of most of my friends back home, I settled in for House One, with the bright optimism that I would practice my French, lose some weight, and be easy access if my parents felt like calling.