Unlearning

Our supervisor Suzanne asked us what we learned during our trip. It was really hard to answer her. It felt like we did more unlearning than learning. This isn’t actually unusual, but what’s unusual is for me to admit this, even to myself. Sometimes after I get back from a trip, I focus on writing down all the ideas which give me a comfortable feeling of certainty. For example, I feel confident that a rural hospital in DRC can make some progress at plugging its leaks, losing less potential revenues, and becoming more sustainable. It seems like in our trip reports, I focus on such comforting islands of truth, while ignoring the raging sea of confusion all around them. Here are a few examples of areas where I feel like I know less than I did before.

1. How involved should we get in church politics?

Both CMCO and CEFMC (Congo’s two major Mennonite church denominations) have been going through a certain amount of upheaval recently. Different people tell us different things, and most people’s point of view makes sense – until we hear the next person’s version. Sometimes I think we don’t have enough understanding of the situation to take sides. However, we do take sides in a way, through our actions: in a general way we support lay initiatives, and involvement of laypeople in church decisions, rather than unilateral top-down decisions. We support free movement of information and informed debate by sharing information when we can. We also require clear reporting and accountability for money that we give to others, no matter who receives the money. And we try to share information about what MCC is doing in Congo, always including specific dollar amounts, even before people ask, so as not to give anyone a chance to use knowledge about MCC as a way of holding power over others. But beyond this, we try to stay fairly uninvolved.

I have quite a lot of ambivalence about whether we should get more involved, or not. By not getting more involved, are we empowering some in the church at the expense of others? Would that happen regardless of how involved we got? Are we taking ourselves too seriously if we think that MCC’s involvement actually makes a difference to anyone here? Or are we underestimating the effect that our involvement, or lack of it, has on the situation? Will we look back in five years and conclude that staying relatively uninvolved helped contribute to more dysfunctional, authoritarian leadership? And yet, how can we possibly refuse to work with rural hospitals just because some faraway, high-up leadership is involved in a conflict or isn’t publishing transparent financial data? These questions continue to niggle at me.

2. We saw first-hand that it’s not a good idea for a hospital to replace an accountant with a cashier, while letting the cashier continue to be a cashier, essentially supervising himself. That is a conflict of interest. But, how does knowing that prevent it from happening anyway?

3. Theft happens. Medications can be stolen right from under the nose of an excellent medical director. Fortunately, the theft was discovered and a new system was instituted in which the pharmacy doesn’t collect money from patients directly. The next month, sales in this pharmacy almost doubled, reaching levels never attained since the beginning of the project. Was this a coincidence? How much other theft is happening that we are unaware of? It’s likely that detailed analysis of pharmacy revenue patterns helped us to discover this theft. That feels kind of good… I guess.

4. It’s better when different donors don’t support the same beneficiary at the same time and in the same way. E.g. WHO giving medications to Kajiji hospital when they already have plenty of medications. Perhaps the recipients of the double gift can be convinced that they don’t need more WHO medications and that other health centres can benefit from these. But the larger question is, how can hospitals here deal with the reality that different donors will always be choosing to give them things, based on their own priorities, and without necessarily consulting the hospital? How should they organize their pharmacy to deal with medications from a variety of sources and with a variety of prices? Technically, this problem is solvable, but only if there is a good, collaborative relationship with the Health Zone office. If that is lacking, then a lot of things will continue to stagnate.

5. When a church’s sound system is turned up too loud, I will no longer endure sitting in special visitors’ chairs right next to the main loudspeaker. I will get up and move to the back of the church, where things are a lot more interesting anyway. The woman next to me will whisper questions and explanations, I get to practice my Lingala, and smile at beautiful babies. The downside is that someone might make a comment from the pulpit about our decision to move to the back, and everyone might stare at us. But after some reflection and consultation with various people, we have determined that we are not deeply offending anyone, and so we will choose to take care of our ears first. In some ways we can fit in, but in other ways we will always stick out.

6. It’s a lot of fun to play “Big Boss, Little Boss” (a card game) with hospital staff, as long as you change the game a little so that the top position is “medical director” and the bottom is “travailleur ordinaire” (i.e. the grass-cutter, sweeper, or cleaner at the bottom of the salary scale). People got really into this game where everyone competes for the top position, everyone gets to heap abuse on the person at the bottom, roles are constantly shifting but things are rigged to keep the top person at the top, and you can complain all you want to about the injustice of it all, in the presence of those people with whom you work every day. It was a good reminder to me that there are many things we don’t understand about how power works in a rural hospital.

7. The air in Kinshasa is extremely polluted. We noticed this from the airplane when, several kilometers outside the city, we flew into a thick white cloud. At first we thought it was a fog or mist, but the pilot explained that we were just back in Kinshasa smog. It’s worse than usual now, at the very end of the dry season. As soon as we arrived, both John and I got headaches that persisted into the next day. Coincidence? Dr. Benza asked John once what impressed him in Europe during our vacation. John said, large trucks that drive quietly with no emissions. We all laughed loud and long at this bizarre concept. In any case, we and our fellow Kinois are all waiting eagerly for rain.

Maybe on this trip I learned that it is OK to stay afloat on the messy sea of uncertainty, rather than docking on an elusive piece of solid ground and holding on for all I’m worth. Or maybe I learned that the ground really isn’t that solid anyway.

The road from Kajiji to Kahemba: a personal reflection on rural community development

During our last visit to Kajiji and Mukedi, I tasked myself to take a closer look at the cell phone enhancer packages that these two hospitals had purchased. They are both well outside the range of the cell towers in nearby towns, so the only means of communication is the two-way radio which is expensive and inconvenient for most of the population. We had great success with the cell phone enhancer in Nyanga so we thought we would try in Mukedi and Kajiji. Unfortunately, it hasn’t been easy. Until recently, we weren’t able to find a location where the enhancer could pick up a signal.

In Kajiji, I suggested that we take a motorbike with the equipment and a battery to test some other locations closer to the cell phone tower. What started out as a mostly technical task ended up being a great (mostly) non-technical experience for me for which I am grateful.

On one of our testing trips, I learned that the owner of the motorbike I was riding with was a young woman who drove all the way from Angola for her fistula operation. Think about that for a moment – bumping around with that condition for days on a motorbike and having to maintain concentration just to hold on, not to mention dealing with the border crossing and dangerous diamond routes. In understand that Kajiji hospital serves many patients from Angola.

 

Makupa and a family at our first location which happened to be a honey processing plant.

 

I also had lots of time to take in the scenery as we whizzed along as I wasn’t driving. I saw kilometer after kilometer of lush growth and fruit trees all along the 50km stretch we were on. We passed through several small villages with lots of children and adults together. Without stopping, Makupa (the nurse-turned-antenna-installer-and-excellent-driver) yells out the status of our mission to the curious onlookers who asking whether we’ve got a signal yet. I wondered what in the world we were trying to do with this antenna. What good would it do anyway? The basic physical needs of the population aren’t being met, and we’re essentially installing a phone? I began to think that although this phone and internet connection would offer a link to the outside world for some and that would be good, that perhaps there were other more significant benefits of us taking a couple of days to explore the options. I thought that maybe the connection with people along the way was a very good thing for me and perhaps for them too.

We had a flat tire a couple of times. This actually turned out to be a good thing! One time, we were quite close to a village and so Makupa suggested with a smile that I could test the antenna while he fixed the tire. There were several families sitting in the shade under a giant mango tree so we pulled over there. As we assembled the pieces for the antenna and asked someone to climb up the tree to hold the antenna, I sat and observed some of the many small children who were obviously curious about the presence of a white man who couldn’t speak and had appeared out of nowhere. I tried waving to some of them and some came to shake my hand. Another small boy who must have been about 2 years old was terrified of me and hid behind an older friend or family member and peered out from time to time to make sure I wasn’t moving in his direction. The uncle laughed and laughed at the boy for being so timid and then we all started to laugh. We got what seemed to be a very good cell connection but unfortunately our amplifier wasn’t strong enough to send back a signal to the tower (3 watts is the maximum strength for consumer products in North America). So after taking the wheel apart twice and reinforcing the gaping hole in the rear tire, we packed up the antenna pieces and started again on our way to the health center. The other day we had a signal there and we were hopeful to have enough of a signal to make a call.

 

Flat tire, turns into 5 bars (but no usable connection)

 

We arrived a few minutes later at the health center which had been recently painted on the outside. We quickly unpacked the equipment and found a long bamboo pole to attach the antenna to. In a room close to where we test, there is a bare room with a single red maternity bed. Presumably, the woman who came to Kajiji for a fistula operation gave birth on a bed similar to this one and as obstructed labor is purported to be the leading cause of fistula onthis continent it is quite possible that during childbirth she developed her fistula. As we walked to a second location close to the building a large group of barefooted children followed us in anticipation of something, anything happening with this weird man (me) and this even weirder metal box and black cable. Unfortunately, I noticed a lot of hospital waste as we walked: used needles, empty glass vials and paper garbage. I’ve found this to be typical of the hospitals we work at and haven’t understood why the waste isn’t at least thrown into a pit and burnt. This, the apparent lack of sterilization, and the more general disinterest in keeping health centers clean and safe remains a mystery to me. At some point, we decide that the signal here isn’t strong enough to make telephone calls. So we are disappointed as this was the ideal spot (after the hospital) to set up the antenna. But, we try not to think of this as a failure. At least, I’m thinking that it was worth the effort to try.

 

This is a tree close to the clinic

 

 

The maternity bed at the clinic

 

The other day, I was at the clinic and I saw a wonderful patch of color on the ground. These were beans drying in the sun. These beans are an excellent source of protein and, if I understand correctly, this particular variety of bean was developed over time from missionaries who brought different varieties of beans from Canada in the 60s and 70s. These beans, tomato sauce, garlic and local rice with a little bit of red pepper is one of my favorite Congolese meals.

 

Colorful beans, a great source of nutrition and one of my favorite meals

 

Our next and final stop for the last day of testing is about seven kilometers away from the clinic. We must first pass over a river on a small canoe with our motorbike. At first it looks like bit risky, but the boat driver expertly and seemingly effortlessly guides us over. This time there are several older men playing cards and enjoying several very small fish that have been smoked over a small fire nearby. By small, I mean 1 cm by 5 cm. The last time we crossed this river, Makoupa said to me that he was afraid of the water. When I asked him for more details, he says he was afraid of the children fishing in the water. I asked him again, “Why are you afraid of the children? Will they come and tip our boat (and your motorbike) into the water? Do you know how to swim?” He says “no, that’s not the problem”. I wait a bit, sensing that he wants to say something further, and ask him again “So why are you afraid? I don’t understand what you mean.” He pauses and then tells “I had a child who was fishing just like that, near the current, and he drowned.” I say that I’m sorry and we are silent for a moment as we look over the quickly moving current.

 

Canoe crossing with Makupa

 

We climb out of the marshy river area and up over a small hill – probably 100-200 meters high. But this is the hill that was blocking our signal from the clinic, I think. On top of the hill we find the church again and in the heat of the middle of the day, we try once again. This time we know it should work because it worked last time. But the first test renders nothing. I’m beginning to wonder if this will ever work. Then we move a few feet away and try again. This time it works! I make a few calls to test and the signal is good. I’m sweating in the blazing sun without any cover except for my black hat. I quickly take out my computer and plug in a 2G modem to test the Internet. It works, barely – and so this might be a location where the hospital staff can come and send reports and receive written feedback. But at the very least, they’ll save time and fuel by avoiding 40 km more of travel or 120 km if they go all the way to Kahemba and back. When we’re all packed up, we snack on some left-over pancakes and a couple of bananas from breakfast and are satisfied with the fruits of our labor. Makupa seems still optimistic that we can make the antenna work at the clinic. I’m happy he seems to have taken an interest in this project.

 

The antenna works near a church building project 32km from Kakjiji

 

As it is so hot, and we have at least 90 minutes of road ahead of us to return to Kajiji, we pack our things up and return to Kajiji. This time the guys at the river refuse to take us back as we have forgotten to bring money. We wait for a while on the canoe while the river guy explains that he will not move until we pay something. Fortunately, I have a banana in my bag which is readily accepted. In fact, the boat owner and Makupa have a hearty laugh over my improvised payment. As I pass over the water, I wish I could dive in take a swim, but alas we have no time nor do I have any extra clothes with me.

On our way home we pass by a little house – actually just a roof with poles. Makupa tells me this where the men drink palm wine. “They are drinking,” he says as we pass by. Palm wine comes directly from a palm nut tree a little like maple water.
I continue to reflect about what we’re doing on our way back. The chances of this antenna actually being set up and maintained are pretty low – even though hundreds of people could make use of it. It is true that it has the potential of connecting a remote part of the world with family and friends and medical supply depots for the hospital. Perhaps I don’t realize how important that is. In any case, I’ve enjoyed this task and getting to know Makupa – who is now confident enough to continue testing on his own.
On our way back, Makupa, who is also a nurse at the Kajiji hospital, recognizes a young woman who waved to him. She was a recent surgical patient at Kajiji hospital and Makupa stops to say hello and asks how she is doing. I’m delighted because she looks healthy and hopeful.

Makupa also points out several spots where there has been a recent motorbike accident in the sand. I am thankful that we did not have accident. Driving on dry sand can be dangerous as the only viable technique requires driving above a certain speed in order to kind of ski your way through.

When we arrived back in Kajiji (no flat tire this time) I learned that the local ANR (the Congolese version of the CIA) had told the hospital that they would have to cough up $300 to have the privilege to set up such an antenna. I couldn’t believe it – I felt myself getting very angry at the injustice of it. How can anything good happen here if the government clobbers every initiative before it even gets off the ground? I have to choose not to do anything or say anything at this time, because I can’t think straight. After our visit in Kajiji came to an end, the fistula patient, now terribly weak and in post-op pain, flew back to Vanga with us and had to wait an extra 40 minutes waiting for the migration police and other airport officials to clear our plane for takeoff even though they had done the same checks just a few hours before. The usually calm and collected MAF pilot returns to the plane clearly frustrated from the egotistical behavior of the airport officials.

 

The road back to Kajiji

 

Although our trip wasn’t exactly an amazing technical success, I am grateful for the opportunities I had to explore the countryside near Kajiji. I am also now more aware of the difficulties – some technical but I think mostly political and behavioral – that remote communities such as Kajiji face in their efforts to make life better for themselves. After almost a hundred years of paternalistic colonialism and nepotistic Mobutuism, communities like Kajiji struggle to survive and develop their identity in this new era of opportunistic neo-colonialism. I look forward to visiting Kajiji again in June 2011 when we have our next scheduled hospital visit. Maybe this time I’ll go swimming.

-John

All in a day’s work: How we and the medical supplies get to the hospitals these days

Anicka and I visit each hospital at least every six months. We do this at the same time the hospitals order supplies so we can take advantage of the flights and avoid the very long trek by jeep. As usual, we traveled first to Kikwit where the supplies are ordered from a local pharmacy depot and carefully weighed and put in boxes with handwritten packing slips. Then, when everything is ready and hopefully everything the hospital ordered was available, we put all the boxes in a city bus called a “City train” and head off to the airport where we hope that our MAF charter will land in an hour or two. Many government officials such as the DGM (in-country migration police), ANR (secret police/CIA), TVA (airport tax people), and representatives of the Congolese air force crowd in for the inevitable “official” verifications and taxes they require before giving us their blessing to take off. Of course, everyone knows we are a humanitarian organization working under the official national organization of churches with an official mission to visit hospitals, and that there is no doubt that what we are transporting are medications and supplies. However, this is one of their few opportunities to make some extra cash with the implied (and sometimes stated) threat of refusing us the right to use the airstrip. So while we wait for all the paperwork to be done, Mr. CIA with his large sunglasses and almost-permanent scowl of suspicion (except for the fake smile when he starts asking for bribes) and his fellow government agents who all look overfed and under-worked stand around anticipating their cut in the fees. Needless to say this isn’t exactly the most fulfilling part of our work.

 

MAF dropping off medications & supplies, and picking us up in Kajiji. The children are always the first to greet us and the last to say goodbye.

 

Once that’s out of the way and we’ve optimized the amount of payload we can bring with us on this flight we say our goodbyes and thank yous and jump on board for a 90 minute flight to our first stop: Mukedi.  We land and drop off about half the supplies and our personal baggage and in a few minutes, Dr. Gaspard continues on the same flight to Nyanga with their supplies and his motorbike. We’ll stay in Mukedi for a week to visit with hospital staff and help them validate and analyze their financial documents and hospital health indicators.

After a week at Mukedi we catch a smaller MAF flight to Kajiji about 500 km to south of Kikwit. This time we go with Dr. Benza who is making a supervision visit for the Kajiji hospital.

 

MAF dropping off medications & supplies, and picking up a patient to take to a larger better-equipped hospital in Vanga

 

Then the plane full of meds comes and drops off the meds and picks us up for the return flight. This time we have enough room to bring a couple of passengers. One passenger is a young woman who traveled all the way from Angola (over a 100km away) by motorbike with her husband for treatment for fistula. She was operated on at the Kajiji hospital and the operation didn’t go well so she was referred to a larger hospital in Vanga where the plane happens to be going. This flight makes a 5-6 day journey into a 3 hour journey. Unfortunately, we had to stop in Kikwit on the way and are harassed by the government officials for 40 minutes before we can continue on to Vanga and she can be admitted to the hospital. She has spent many days already recovering from surgery and has lost a lot of weight. We hope that she survives.

Then we continue on the same flight all the way back to Kinshasa where we are greeted by a thick cover of smog and the regular (and more pleasant) government officials at the N’dolo airport. We are grateful to MAF for their friendly and professional support.

-John