Guinea Top Fives...

Here I am, signing in for a last little update, as I await my British Airways escort back to Canada. Have said my goodbyes, packed my bags, and am hoping that I have dodged all things winter! I am easing the transition with a few weeks in Francophone-ville, so I can at least parler en francais un peu plus. So much to say and yet not at all sure how to sum up all that Guinea and MSF has kept me contemplating; so how about a lengthy few “Top 5 (or so) Lists” to summarize things...

Top 5 Things I Look Forward to as a Midwife in Canada

• A publicly-funded healthcare system! MSF was paying fees to the health centre staff for all patient consultations so that patients received free care. This encouraged local staff to inflate the number of patient consultations they reported. For example, if a pregnant woman came in complaining of fatigue, nausea and pain, the practitioner may report 3 separate consultations (one per complaint). It is exhausting to police and control and I yearn to provide the best care I can, without worrying about money or fees!
• Hygienic toilets! MSF installed functional sanitation systems in the healthcare centres, but then staff and other random onlookers took it upon themselves to start charging people to use these facilities. In turn, this led to people urinating and defecating anywhere but in the toilets, to save a few coins. I can’t wait to provide my services amidst conditions of better sights and smells!
• Working within a context of privacy and confidentiality. Call me “stuck to Western habits” if you will, but I think that a bit of privacy and confidentiality can be a really good thing when it comes to pregnancy, birth and all things reproductive health. I never got used to the fact that Guineans share their history, HIV status, birth and gynecological procedures with a crowd of onlookers. I think privacy can be a really respectful reality!
• Soap, clean baby scales and baby resuscitation equipment.
• Being able to follow-up with patients because they have an address, a telephone number and they do not have one of five local names shared across thousands of people.

Top 5 Things I Don’t Look Forward to as a Midwife in Canada

• Working in environments with epidural access. I really love supporting natural childbirth and when epidurals aren’t available, labour just works how it is supposed to. Women complain less and birth works better!
• Going back on-call. I have not missed getting up at all hours of the night, often to work “shifts” of 24 hours or more. I have thoroughly enjoyed 8-6 days and nights without phone calls pulling me out of my cozy dreams ;)
• Working in medical environments who think that infant formula is as good as human breastmilk for babies, and who neglect to use practices that enable mothers to effectively breastfeed their babies. In Guinea, water quality is so questionable that everyone is forced to prioritize breastfeeding in a way that we do not in North America. It is such a pleasure to work within an environment that REALLY supports breastfeeding, rather than just putting up posters that make it appear like breastfeeding is supported.
• Medical charting! We spend more time and energy charting things and providing legal justifications of every damn thing that happens around a birth in Canada, that we are seriously drawn away from our real work. In Guinea, charting consists of completing a form or two if so inspired. Furthermore, if something is charted incorrectly, one simply erases it and rewrites it. If something was not charted at all, it is perfectly okay to add it later at whim. Not particularly effective as far as high-quality care provision is concerned, but certainly a nice break from the defensive medico-legal charting that is required of practitioners in Canada. It was so lovely to be free of medical-legal paranoia and a culture of fear-based medicine, which enabled me to practice the real art of medical care...making decisions that make sense, based on intuition and available information, rather than everyone doing what they think they should do to “cover their asses”.
• Working in an environment where more than 1 out of every 3 babies is born surgically. It is clearly true that birth outcomes were worse in Guinea than at home, but nonetheless, the very low cesarean section rate did not translate to 1/3 babies not surviving the birth, which is what we are led to believe would be the outcome if we did not maintain the 30% cesarean section rate across Canada. We are so excessive with our cesarean sections and I loved working in a place where surgery is not a “normal” way to be born!

Top 5 Realities of Guinea that I can Easily Leave Behind

• Military men bayoneting people for whatever displeases them, regardless of how insignificant an “infraction” may be
• If you leave a parked car, chances are the tires, battery, and gas will be stolen within a few minutes to hours
• The parade of people asking for money each day on the way to work. Every single day on the way to work, we say no to lineups of folks looking for money. It is a security rule for the organization to never give money, as it can place us as targets for those in need. The gang of people each day includes albinos, people with visible disabilities, people with visual deficiencies, twins and triplets. Some are there because of need, others because of local beliefs about the luck that accompanies giving to such people. The parade was always a bit of a tough way to start the day for me.
• Female circumcision. Am all about cultural preservation, but it gets hard for me when this reality pops up...as it does for 97% of women and girls in Guinea.
• The heat and humidity! It is not only hard to live in, but it is incredibly challenging when trying to run a healthcare program the depends on a cold chain for medications and vaccinations. Meds and supplies spoil nearly instantaneously if not refrigerated here and refrigeration in Guinea requires electricity, and that is a whole other reality that is far-from-happening...

Top 5 Things I am Really Going to Miss about Life in Guinea

• The incredibly welcome and sweet folks who so warmly embraced me, even though I was another white gal coming as part of another NGO to try to make them do things “in a better way”, with little understanding of their realities and without any intention of staying. Humanitarian workers have done some good, but also lots of harm, and I have been completely blown away by the welcoming nature of the Guineans who have opened their lives to me, despite the challenging history of all that I represent in my role there.
• The music and the dancing! I love love love being able to see amazing live Guinean music all the time. And I love dancing to it when I can draw up the courage to dance beside Guineans who are born with the gift of dance in their blood.
• The fresh-from-the-source selection of fruits, of which at least a few kinds are in season at any given moment. The oranges, the pineapples, the mangoes... :D
• All the funny everyday local sayings that have deeply charmed me. For example, “invitation” at the start of every meal, “chose” to address anyone whose name is not on the tip of the tongue, and the ridiculously long greetings at every encounter asking about your day, your “service”, your family and your health.
• Watching newborns transition into the breathing world without medical tampering. I get to witness it often enough at home, but not in the same way that I have in Guinea (rules and regulations don’t permit). It is amazing to see how wee humans figure out life outside of the womb when anxious medical folk don’t take over...

Top 5 Humanitarian Realities that Irk Me

• In Ugandan public hospitals, international students (like I was) are required to pay a fee to volunteer (doing work that would not necessarily have been done otherwise). The utilization of these fees is not at all transparent, and presumably enter the corrupt upper echelons of the health care system and governing representatives. In Guinea, there are way too many staff, students and volunteers in the hospitals, yet they do not ask fees of volunteers. While in Uganda, I was part of UBC putting money into the pockets of corrupt overseers and unless we insist on contributing only to the base of the pyramids around the world, we ain’t gonna get anywhere! My experiences in both countries showed me that hospital directors have air conditioning, fancy watches and telephones, etc...while the rest of the hospital often doesn’t have the resources needed for really basic care provision (like electricity, water, or sterilization capacity). All of us involved in humanitarian work either on the ground or as donors need to take steps to ensure our money is going where we intend it to go!

• The price tags for many of the products and services purchased by MSF in Guinea are super inflated. Anyone negotiating with any international organization (including NGOs) will inflate the price like crazy, and furthermore, even national staff working for the NGOs often take a cut from transactions. For example, MSF had to replace the screen at the staff housing to prevent mosquitos from coming inside and the service men were paid a salary worth 2 months of work for a project that took a day. These means that donors’ money gets absorbed in commerce rather than landing in the hands it was intended to reach. From the NGO perspective, it is a challenging trade-off...should the expats spend time and energy researching and bargaining for the best prices, or should they delegate negotiations in order to be more efficient? It just feels so lame that NGOs are seen by locals as an international “business”, akin to a bank or mining company or arms producer.

• The adherence of NGOs to WHO guidelines that are based on evidence but not reality. For example, we have to keep giving out mosquito nets to prevent malaria, because evidence shows it is effective. Reality shows that distribution programs don’t work (there have been over 5 in the last 10 years in Conakry, and good luck finding a mosquito net being used for anything other than fishing line). NGOs adhere to a bureaucracy that isn’t always compatible with common sense.

• Many African populations have been visited by so many international volunteers and organizations who come to highlight what they do wrong and try to convince them to do otherwise, that they have rightfully become extremely defensive and skeptic of the white folk that come their way. It makes it nearly impossible to review cases with poor outcomes in the interest of learning and improving care, because there is no context for open learning; instead, everyone works hard to cover up facts, hide truths, and defend whatever the moment inspires.

• Collaboration is a lovely intention of NGOs, but really working within local contexts and with local people is incredibly challenging in light of all the realities that surround the history and other massive differences between NGO staff and local life. Projects (such as the one I have been a part of) often get started and struggle to move forward with real longterm collaboration from locals (for too many reasons to get into). If these projects stay, they often spend lots of money and accomplish little. If these projects pack up due to lack of real collaboration (which is necessary for longterm outcomes), they become another NGO to come and go...adding to the already entrenched trail of anger and mistrust. It is hard to collaborate between corrupt governments, multiple international NGOs, and those working on the ground.
• 

Top 3 Random Things that are on my Mind

• A while ago, there was a crowd of people around a cemetery near one of the health centres. When I asked what had drawn everyone there, I was told that people were protesting against someone who stole various body parts of a recently buried albino. Apparently these parts are offered as sacrifices in the ocean (along with food and plastic trinkets and fabric)...because albino body parts are particularly valuable to God.
• MSF gave one of the health centres a couple new benches to be used in the waiting area for pregnant women awaiting consultations, who otherwise have to stand in pretty extreme heat. Each day I found them stacked upside down. When I asked why they weren’t being used, I was told matter-of-factly that if they are not kept upside down, women sit on them and talk loudly, which is disrupting for the medical staff; apparently, it is best if they are kept upside down and empty.
• One of the midwives (an educated, muslim, middle-class woman in her 50s) casually explained to me over a long discussion how she prefers diarrhea to vomiting. She gave me detailed pros and cons of each and really was determined to convince me how much better diarrhea is compared to vomiting. It was a seriously strange conversation for me, but in a place where both realities are commonplace, I suppose it was well-rehearsed for her...

Finally, I’ll sign off by sharing a few of the local traditions related to childbirth, which is really such a fascinating part of international midwifing.

In Conakry, the local tradition after the birth of a baby is to bury the placenta in the earth, layering both sides of it with leaves. In urban areas where this isn’t always easy anymore, the placentas from health centres are collected in huge plastic barrels and hucked into the ocean. Lucky fish who come across those barrels ;) It is also traditional for families to keep the umbilical cord stump after it fall off (typically within a week of the baby’s birth). They usually tie hair around the stump from the baby’s first haircut which is often done on day seven after birth, which is the day of the baby’s naming ceremony. The umbilical stump wrapped in hair serves as an object of good luck. It can be tied around the baby’s neck or waist to protect the child. The midwife that I worked closely with has kept her daughter’s (who is now over 20 years old) and she holds it while praying for her in times of struggle or lack of clarity.

(This family benefited from the tin of change with a surgery for the wee lady to help her walk. They are happy, they just don't typically put on big smiles for photos here!)

Chin chin, santé, cheers...to all the wee Guineans who have come onto the planet in the last six months. And to all the other babies around the planet too...

random complexities i am thinking about...

i realize that i don't really love blogging. i don't say that as a universal statement, but i just don't like it for myself. it feels so one-sided and weird. i look forward to sharing cups of tea and having face-to-face conversations (in english!) with my family and friends one of these days ;)

today i will spew out random things i have seen and learned while at the health centres here in conakry. a mixed assortment of tidbits that have stuck in my brain and intrigue me:

(that is denise, my midwife partner in crime, feeding colostrum to a premature wee one)

- the WHO recommends the distribution of mosquito nets to all pregnant women in countries where malaria is endemic; mass distributions of mosquito nets were done by various NGOs over the last decade here...2006, 2008, 2010. when our community health agents go door-to-door, we find there are almost none to be seen. MSF follows WHO recommendations, hence we are distributing nets to all our pregnant patients, despite many proven failures of mass distribution programs. after 6 months, we have found that about 8% of pregnant women are using the nets we distributed. they either bring them home and stack them neatly on a shelf (with pride), they sell them, they gift them, they use the threads as fishing line, or the net itself is used for shrimp fishing. they report that they smell bad, they inhibit air circulation (making it too hot to sleep), their husbands don't like them, or they didn't have a hook to hang it. each mosquito net costs about 5-10 dollars and over the years, i can't imagine how much well-intentioned NGO money has actually gone into shrimp fishing!

(isn't she the sweetest little shrimp!?!? guinean babies are sooooooo lovely!)

- i watched our community health agents go door-to-door (figuratively, because there are rarely doors)...as they spread preventative health information to families, such as the importance of mosquito nets or proper waste management ideas. typically there is a group of 10ish people who gather to listen to the agents, and of those people, 3-4 pay moderate attention to what is being discussed, but most don't even pretend to be listening. then everyone claps and says thank you and they get on with their day. i wonder how many times each family has had some NGO-backed person come give a speech...i wish i could speak their language and ask them what it is like to be on the recipient side of international development programs. the concept is great and their are good outcomes sometimes, but my experience really made me feel how disengaged people seem to be when yet another aid organization comes to tell them what to do.

(two babes born to an HIV-pos mama, who have a 99% chance of not being infected :D)

- i shook my head and laughed when i saw one of these same health workers (MSF employees who, i remind you, are spreading public health messages on our behalf) take a piss right outside the main entrance to the health care centre. we put in toilets, but they have decided they are so new and nice that it is better to keep them clean and pee around the health centre instead. furthermore, certain individuals have deemed themselves guardians of these toilets, and they charge people to come in, further encouraging their disuse. basic hygiene can feel impossible to attain sometimes!

(donations of medical supplies are lovely, but maintenance of these gifts is a whole other story...)

- since our program started in 2009, the number of people coming to the health centres in which we work has gone through the roof. mostly because we are providing free health care to our target population (children under five and pregnant women). the most challenging side effect is that what were once appropriately sized structures are now disgustingly overcrowded, making quality healthcare provision nearly impossible. we have unintentionally worsened the conditions of the consultation spaces and we have seriously aggravated the staff who work there. it is trippy how we have created more needs by trying to meet existing needs. so to address this, we are doing renovations and improvements to the facilities, which is an expensive undertaking, only to wonder what will happen when the project is over. will these health centres be an addition to the many many beautiful but empty health care facilities all over africa?...facilities that are no longer frequented because people can't pay or because they have no more medications/supplies.

(our birth beds that MSF donated a couple years ago)

- this is a good one! we were reviewing the names of staff members who are listed as paid employees by the Guinean government at one of the health care centres. we wanted to try to figure out who within the structure is actually supposed to be there (as the units are packed with various people in medical uniforms, some of whom are trained, some are volunteers, some are students, some are just people who have a medical coat and want to come make money...it can seriously be a feat to try to figure out who actually has some expertise). you can imagine how interesting it can be to try to improve quality of care when some of the midwives turn out to be cleaning ladies who inherited a lab coat! anyhow, we noticed that there were three pharmacists listed, but actually, there is only one pharmacist at the centre. the director informed us that the other two went to work in europe a few years ago. he went on to explain that many of the listed names are people who now work in europe, but the government hasn't updated the lists in a long time, and nobody enforces employee presence or absences. so while the government spends about 1% of its budget paying health care workers, who knows what percentage of that money is actually being paid to doctors overseas who don't even live here anymore. amazing! not to mention the rest of the list, which consists of people who come to work for a few hours a day, a few days here and there, etc. etc.

(a paediatrician from geneva teaching our staff about care for premature babies...a concept that is really new here. they tend to accept that strong babies live and weak ones die, and trying to engage them in newborn care is really asking for a huge paradigm shift it seems)

- another lame side effect of our project is that we have made healthcare free; so women are told never to pay for any services or medications they receive. the cleaning ladies at the centre used to get tips or gifts of soap from the patients, but now nobody pays them anything. so we have chosen to give them a small stipend, but it isn't enough, and rumours suggest that they sometimes work as midwives in the community, attending births at home to get more money. the situation doesn't necessarily lead to improved outcomes for our target population. and despite being a big advocate for home birth in canada, home births with cleaning ladies in guinea aren't really something i want to encourage.

(this is one of my favourite wittle ones...)

clearly there is a lot that needs to shift here in order for health care to really improve, but it is so damn complicated. so much disorder, lack of follow-up when it comes to medicine and administration, lack of hygiene, a medical culture that lacks compassion (not because people want to be mean but because they are overworked and need to make ends meet), no privacy, overcrowded conditions, theft, waste management concerns, no food for patients, little concern for sterilization, nothing is labelled, protocols don't exist or aren't followed, delays in every step along the chain of care. it is hard to know where to start. as per my last post, i am trying to just exhibit good habits and see if it catches. it seems like it does, if i am in the room watching, but when i leave for lunch or turn my back...not so much. but we have to keep our chins up and do the work that needs to be done, right? ;)

AND...seriously, all the little ones getting life-changing surgery because of our tin of change bring much light to my work here!

(i have never seen a newborn casted like this before and find it quite charming)

(a family that thanks you for your support!)

she gets an urban escape

but just by a hair!

i had been planning to take a long weekend in the interior of Guinea, in search of clean air and a repose from traffic jams. but then life spiralled downward for a wee bit there. i started brewing feelings of anxiety and borderline panic, but without any particular source. at first i thought maybe something bad had happened to someone i know, or something bad was going to happen. my colleagues insisted it was just normal fatique and need for a holiday, confirming that all MSFers start to feel really poor after three months or so. (this was kinda reassuring, yet also not at all!) i am not generally an anxious person, so it was interesting to live with symptoms of anxiety for a week there. then just as the anxiety started to lift, a serious fever stepped in. it came overnight and the next day i tested positive for malaria and typhoid fever. it was mighty interesting accessing heathcare services for myself, rather than being the healthcare provider. i was sent to one of the best private clinics in the country, and was shocked at how seriously poor the care was. i laughed to myself as i felt there was no choice but to be a "non-compliant patient". i refused the non-sensical treatments they proposed, signed myself out against medical advice, and took appropriate treatments from our project's medical doctor. but it made me really trip out on how poor the healthcare provision really is here. if one of the best clinics is offering ridiculous screening tests and treatments (surely as a means of making money), you can certainly imagine what is going on in the lower quality services. and don't get me started on the process of just getting to the clinic! imagine feeling as sick as you can possibly imagine, then imagine yourself feeling sicker than that. next, imagine getting into the back of a four by four, and bouncing through massive potholes for over an hour, inhaling noxious fumes from trucks that spew toxic black tar, smoke from burning garbage piles, and a bounty of smells related to various manifestations of human waste. seriously...it was sooooo less-than-fun.

anyhoo...i put in my three days of sweaty delirium (will spare the details), survived the worst headache of my life (which followed a fainting spell with a head crash on the concrete enroute to the bathroom), and i was tip top shape for christmas eve. so my fears of spending christmas home alone in bed vanished with the noise and stank of the city, as i got to go into the interior afterall. it was a beautiful trip through rural areas into a town called Kindia. the landscapes here are absolutely incredible; some of the most lush forests, beautiful rolling hills, drastic mountains and rock faces, sweet typical mud and straw homes, and fruit stands a plenty! the difference between urban and rural Guinea is really impressive. one step out of Conakry and there are few vehicles, few shoes, few recognizable items from the occidental world. instead, there are lots of naked kids running around, no shortage of back-breaking agricultural work, lots of friendly smiles and waves to the white folk (rather than requests for money or help)! it was all a welcomed shift if only for a few days.

stepping away from our project not only gave me some needed rest, but it gave me the distance i needed to put things into perspective a bit. you can't underestimate how challenging it can be to work and live with the same team, with security rules that really limit your freedom, all within a context that i am finding uber stressful and within a cultural context that can feel so hard to integrate. i had the space to really acknowledge that i have been readily losing motivation for my work here, and the layers of mounting frustration and roadblocks have left me feeling exhausted and lacking hope. we are trying to improve quality of care with a team of healthcare providers that generally chose their profession because it can earn them money to feed their families, not because they have any particular interest in the vocation. we are trying to improve access to equipment and medications, that consistently disappear. when i try to research current practices within the centres, everyone lies to cover up what they really do, knowing that their practices aren't optimal, and leaving me with an array of stories, but no idea what the truth is. not surprisingly, it can feel hard to move forward. but this weekend, while walking through fields of grasses and swimming in rivers, i was able to shed some of my frustration and gain some clarity about how i want to approach my next few months here. some internal spring cleaning was needed this holiday season indeed!

so i tried to shed some of my cynicism, my toughened shell, and my fatigue, to create space for a renewed sense of the humanitarian spirit. MSF requires volunteers to leave the country on holiday every three months and i now understand why. the humanitarian spirit may be strong among many of us, but it needs to be continually nurtured, as it can take a violent beating in these environs!

to say there are challenges is an understatement, but as i only have a couple months left, i figure i need to at least walk away feeling like i kept some sense of my original motivations alive throughout my actions here. so i am going to step away from teaching and try to instead just demonstrate. i find that when i teach, there can be alot of resistance, especially from the older midwives and doctors who have probably had enough white people who know little about their worlds, come and tell them what to do and what not to do over the years. i can definitely understand why they are not always receptive to external input, and while it is hard to watch them do things we know are unsafe, i am not really getting anywhere by trying to teach them. so i am going to try to just demonstrate and influence those who are receptive, rather than spending energy trying to convince those who are not open to change. a simple enough idea, but it takes a lot of patience and tongue biting to witness some of the things i witness (particularly for an Aries like me), without stepping in to try to convince people to change their actions.

let me give an example of one of the issues i am working with. episiotomies (cutting the vagina to make it bigger at the time of birth) are practiced really routinely here. we know that routine use of episiotomy leads to increased infections, poorer healing than natural tears, and more longterm pain, etc. already, 97% of women are circumcized here, so they already tend to have scar tissue and other side effects from the procedure. i have been encouraging them to consider only performing an episiotomy if the woman already has significant scarring or if the baby is in danger. but they don't listen to baby heart rates here, so they don't know how to identify if a baby is in danger. so we put a handheld ultrasound doppler in the centre so that staff can listen to heart rates and avoid cutting women if the heart rate is normal. but the battery is always running out. the hospital director is supposed to pay for replacement batteries with money he receives from NGOs but he instead spends the money on air conditioning for his office. the gel that we need to use with the doppler is often stolen, so some of the midwives bring in their own karité butter, which then gets stolen. so then everyone is mad that the batteries are never replaced and the gel is always stolen, and everyone is then afraid that the machine will be stolen next, so they have decided to keep it locked up in the director's office. so there it sits, safe, without a battery, and not in use. and the episiotomy rate maintains...

my other ongoing issue, is handwashing. there is no water. so MSF pays the cleaning women to bring buckets of water into the birthroom. we also provide soap. it gets stolen. so the soap is stored safely in the director's office as well. everyone is happiest knowing that it won't get stolen there. so nobody washes their hands. we give donations, they sit nicely locked in offices and all carries on as usual...

so i have to hop off to work now, and i will keep my chin up...demonstrating good practices, but teaching nothing. we will see if my spirits can stay up this way ;)

Winter Harvest

We’re sailing into December and so ‘tis the season for juicy pineapples, followed by mmmmmmangoes. I will happily trade in turkey and cooked carrots for fresh fruit any day… let me tell you! There are papayas and “apples” (which have nothing to do with our version of the apple) growing in the yard, and coconuts just down the road. The selection of fresh fruit isn’t particularly hard to get used to.

I feel sooooo far from winter and the accompanying holiday season, but am at least diving into the spirit of giving, thanks to the generousity of my family and friends. I have finally started to share the donations that were poured into the Tin of Change, and I feel really honoured to be entrusted with the capacity to do this. In Uganda, my priority was to use the money in a way that would benefit as many people as possible, and was really stoked with the mattress project that we created. I had originally envisioned doing something similar here, but it isn’t feasible here. MSF apparently provided beds and mattresses to the tertiary care hospital here a while back, and most were stolen. Compared to Uganda, many of the needs are the same, but the poverty is greater and the infrastructure is less, so donations that will endure are harder to offer. And as MSF is providing free healthcare and medications, short-term needs are already being addressed. Evidently, I have been a bit stumped about what to do with the donations from the Tin of Change. This can obviously seem baffling, as I am surrounded by poverty and unmet need. But I want to be conscientious with our donations, and not just act like the many NGOs that I so often question and criticize.

So I couldn’t think of long-term donations that could be put in place and would stay in place, and immediate needs are being met within the MSF program. However, a few weeks ago, “the perfect request for help” presented itself as I was hoping it would. A young first-time dad, displaced from Sierra Leone, approached me at one of the health care centres. He doesn’t speak French and he heard there was a “foutay” who spoke English working there. He had his newborn girl with him and asked if he could consult me about a concern he had with her. I brought them into the Kangaroo Care Unit and he removed the blankets over her legs, to reveal her bilateral clubbed feet. He explained that he was told she would need 5-7 weeks of casting, followed by a surgery. Without the treatment, she will never walk. With the treatment, she will scamper, run, jump… The MSF program that we are currently running, pays for acute healthcare related to malaria, malnutrition, and respiratory infections. The program will also pay for emergency treatments such as surgery, if the condition is life-threatening. This baby’s condition is not life-threatening, so the surgery is not covered by MSF.

A beautiful opportunity appears! I decided that MSF can deal with the life-threatening stuff, and our Tin of Change can deal with life-changing stuff. I am abandoning hopes of changing the world for lots of people (which can’t happen in a context of persistent poverty, and in a place that is being systematically raped of its riches by the occidental companies that make your and my life so convenient)…rant rant rant, where was I? So I don’t know how to use the Tin of Change to benefit many people, but I know that by supporting babies and children to have life-changing treatments, the worlds of a few will be mighty brighter. Being in a wheelchair in Guinea is not a peachy reality (the quality of life for those with disabilities here requires an entire blog unto itself), and for about $40, this girl can lead a normal life. And so the non-life-threatening-but-life-changing-surgery project is born! I am open for referrals from within our health care centres, but also encounters that arise when I am out and about.

I get the impression that many Africans struggle with the Western need to prevent death at all cost, and there are some real cultural clashes between the way we perceive and negotiate death. I feel like rather than preventing death, this use of money is more in line with local ideals of maximizing health and enjoying life, but not getting as caught up in “death prevention” as we tend to. In Uganda, I really started to see how the western need to prevent death at all costs was super weird; my time in Guinea reinforces the same notion. It is really normal for most people here to have lost many family members, and likely some children. But they are not feeling sorry for themselves because of it, and they don’t always understand why we feel so sorry for them. I think they would rather all energies be put into just international policies, political structures void of complete corruption, and opportunities for development and employment, rather than using energy to try to save every last human. It is not that life is not valued here, it is just that life within a context of poverty is really hard, and maybe it is better to improve quality of life for fewer, instead of quantity of life at all cost.

Here is a photo of our first beneficiary… she has had a month of casts so far, and will have her surgery before Christmas.

the 9-5

here's my work day in a handful of photos:

this is the big hole on my street.

it's all good in the daylight, but can be scary at night.

this is the road to work. bumpy. soooo bumpy.

this is the beach / dump.

this is a burning car outside my office.

this is the office.

this is the cold chain where vaccines are kept.

this is Denise, the midwife that i work with.

she has a daughter nearly my age...

but you'd never know it!

this is the work gang.

this is the kangaroo care unit we are opening here.

everyone calls me mariama kangaroo as my guinean name.

this is a preemie baby kangaroo in our care.

this is the neighbourhood riff raff.

this is what happens each night when i wash conakry out of my hair...

this is monsanto in africa.

and that pretty much sums it up.

bumpy roads, lovely staff mates and special carrots.

Stepping into November...

...makes me realize that time is going by so quickly and so slowly all at once. When I look at my to-do list within our work goals, time is flying by far too fast, but at the same time, days can be oh-so-long here. I think that big African cities are perhaps not the environs that inspire me with the most energy; the "special" smells, the pollution, the traffic, the heat and humidity...they make the days long! And as my relationships are developing with folks here, I get the feeling that I've been here forever.

(a few members of our team outside the hospital)

This evening's blogging will highlight some of the cultural differences that have struck me the most strongly over the last 6 weeks. I wanted to write about them a bit, because I am realizing that what I used to notice as interestingly different, is fading into normalcy very quickly...

- The greetings and formalities here are abundant. Every day as each person encounters one another, a long greeting, with handshakes and questions about the well-being of everyone's families and homes ensues. I try to get away with a quick round of high fives, which seems to be entertaining people, because I don't have the patience for the rest of it. It was the same way in east Africa, so I guess it is widespread. Maybe we used to do that before we became overworked, stressed out and estranged from our neighbours?

- In contrast to the extensive greetings and pleasantries, there are other aspects of how people interact that seem so "uncivilised" through my North American lens. Our staff meetings, which are mostly comprised of national staff, typically involve much shouting and constant interrupting. I find it so hard to communicate here because A) I'm speaking French, B) I don't particularly want to engage in the yelling, and C) I am interrupted so much that I lose inspiration and forget what I was going to communicate. In the maternity ward every day, I continue to be impressed with the behaviour of the midwives who yell at each other (and the patients), grab at each other, push and shove each other (and the patients), and if I'm not careful, I definitely get jostled to and fro. It is surprising for me to see adult women interact this way, when I am much more accustomed to people being passive aggressive and bad-talking behind others' backs.

- When I'm ducking out of the midwives' frequent angry eruptions, I laugh to myself as I notice how I can really feel like a prude here (which isn't a feeling I typically experience). I try not to jump when folks hork up massive balls of phlegm and propel them wherever the moment inspires. I try not to giggle when people start picking their noses in the middle of speeches or meetings with affluent leaders. I love a good nose pick as much as the next gal, but I have never seen people go to town in professional situations like this! My biggest prude obstacle arises in the realm of cell phone manners, which I think are quite non-existent at home, but are even less-so here. In the middle of a meeting or a presentation or a meal, nobody thinks twice about answering their cell phone and talking loudly for as long as they are inspired to do so. There is no concept of turning off or turning down ringers in any situation, and in fact, people here usually have 2-3 phones with the various spotty telecommunication services, so that at any given moment, one will hopefully work. It makes for a lot of cell phone interruptions! Between the interruptions that are normal when talking in person, and the interruptions incurred by cell phones, I can see why it is hard for people to get ahead here ;) I enjoy picking my nose freely though, so that keeps my spirits up!

- The majority of people here are Muslim, and I love hearing the call to prayer that emanates from the mosques throughout the day. I asked one of our drivers if he drinks alcohol, as it seems that most people are quite liberal in their practice. He told me that he doesn't "drink" alcohol, but he "tastes" it. This expanded into him telling me that on weekends, he likes to have 5 or 6 beers after work, then drive home and go to sleep. He assures me that if everyone did this, we would all be so much more stable. Liberal Muslims abound indeed, and apparently so does drinking-and-driving. Interestingly, I found out that the woman who does our laundry is less liberal... After days of wondering why I had no underwear, I found out that the women here don't wash others' undergarments because of some religious conflict I don't quite understand. Good to know.

- The pace of the work day and the general work ethic here is pretty darn far from what I experience back home, which can feel nice and frustrating, depending on the winds. I have moments of savouring how low expectations can be for accomplishing things, but then my hyper-driven work ethic kicks in from time to time, and I start pulling my hair out, wondering why people can't do things just a bit more efficiently or quickly. I waiver between wanting to adopt a work ethic more like this when I am in Canada, and wanting to put some fire under the feet of folks here to MOVE...

(one of the Guinean babes getting care)

- A few things that make me laugh: I keep picturing a cartoon about a HOV lane in an African city, because every vehicle is so far beyond high-occupancy that the other lanes would host only the SUVs of all the NGOs working here. I also laughed when I went to a lovely outdoor swimming pool and saw the lifeguard spend his whole afternoon, not looking at all at the pool, but yelling at the patrons to step throwing their garbage on the pool deck; the garbage pails all sit empty, but the pool deck is elaborately decorated with litter! I also find it hilarious that everybody keeps the manufacturers' stickers on their glasses lenses here. Not sure why, as it definitely can't make vision any clearer. But it seems nearly universal, they all keep the stickers on their lenses.

- Speaking of glasses, many people need them here. Every time I go into the health centres, people pass me document after document to read out loud so that staff can understand what is written. It is hard to be efficient or get ahead when nobody can see their work!

- And now to finish, I'll tell you about two people that stuck with me today. The first is a nurse that I work with at one of the centres. He was explaining his family to me, and nearly exploded my brain. His dad was the chief of his village, so was lucky enough to have 27 wives. (27...not a typo!) His mother was the last of his wives. She added 8 kids to the grand total of 76 kids that were fathered by his dad. He is the only boy of those 8 kids, and he is hoping that he can keep working with MSF nearby his village in the future, as he wants to be closer to family. And that is one seriously bountiful family! The other person that stuck with me today, was a man about my age, in a wheelchair, labouring to slowly wheel himself through the polluted streets this afternoon. It was so hot and so humid, and the sun felt so unfair in that moment. He was wearing a shirt that said: "Put yourself in my shoes". And despite the fact that ironically, he didn't have any shoes, I took a minute to really try to imagine myself being born into his reality. Harsh. I can't get him out of my mind.

Protests in the city!

Last week was an interesting one to observe. Being my first stint with an NGO, it was intriguing for me to see how the organization responded to an anticipated political crisis. Two years ago, on September 28th, there were protests in response to the non-democratic arrival of a new president. The army responded by raping, mutilating and murdering thousands of protesters, torturing and raping first, followed by open fire afterwards. [Insert deep inhalation and deep exhalation].

In anticipation of this anniversary, and an upcoming election due for December, there were increasing concerns in Conakry about anticipated protests and potential violence, all with some pretty serious ethnic tensions weaved into the mix. The opposition was certainly provoking protest, while the government was prohibiting it. The national MSF staff members were informing us ex-pats about their perceptions, and we were anticipating the worst while hoping for the best. In the worst case scenario, my role was to respond to victims of sexual violence, performing genital repairs, gynecological screening tests and counselling (because my understanding of the local language is so advanced!) In the best case scenario, I was under house arrest for 2 days, not permitted to be out and about in the city.

In the end, we experienced a near best case scenario. 80 people were wounded in the protests and 3 were killed; unfortunate of course, but an improvement in stats compared to years past! It felt like we were so over-prepared, with tonnes of medical supplies, a huge plan of action in place, and extreme security measures. But how does one anticipate a situation like that? Things can stay relatively calm, or things can explode into a nightmare. Obviously the folks leading our project know to prepare for the worst, but I really appreciate now how hard it can be to anticipate "mass medical need" in places with such political instability. On top of having to organize supplies and staff and procedures within our NGO, much coordination has to happen between all the NGOs working here (other MSF projects, Red Cross, Save the Children, etc...) It ain't no easy feat.

It was really fascinating for me because I felt really safe and had no worries at all about my well-being, but was able to see the inner-workings of how NGOs anticipate response to emergency political situations. The children of MSF ex-pat staff members were evacuated to Europe, because it is too traumatic and challenging to do it as an emergency is underway. And the rest of us were all given the choice to stay or leave. I think we all felt really safe and mostly everyone chose to stay, but it was nice that everyone was given much autonomy and space to work within personal comfort zones.

This week, work carries on as usual...I will share a few photos to show that world!

A Week In...

I'm just gearing up for my second week of work here, although I can't really say I'm "working" so much as "learning" at this point. There are so many complexities of how MSF works, who all the team members are, how we are to work effectively together and between ex-pat and national staff members, how we are to collaborate with the health care providers working here,... and then there's all the learning that is needed to understand things like the political context of the healthcare system and the community within which we work, and the many cultural pieces that must be understood. I'm also really cognizant that many humanitarian workers have come before me and rather than jumping into any action, lots of questions have to be asked and histories of what has been tried before must be considered. All the while I'm working hard to refine my French, adapt to the local accent and expand my medical vocabulary. I also have tonnes of learning to do about HIV and the prevention of mother-to-child transmission, as well as malaria in pregnancy/babies, etc. etc. I am taking it all in and trying to not get too overwhelmed!

The details of what I'm up to here are yet to be really understood, but the basic deal is that I'm working in a project in one of the poorer (but not poorest) neighbourhoods in Conakry, the capital city. I am involved in 3 health care centres that provide pregnancy, birth and children's health care. We refer to the big tertiary hospital if a case is particularly complicated, although the referral hospital has a mortality rate of 25% for children, so it's not the cosiest back-up option. They also functioned at an average of 150% capacity over the last few months, making the quality of care a big issue. That being said, we are working within the existing health care system and MSF wants to collaborate from within the system, rather than ignore the usual policies and referral processes...so that's the context. I am working with a local midwife who has been overseeing the centres, and we are providing free prenatal care and birth care, followed by free healthcare to all kids under the age of 5. It's incredibly complicated to offer free healthcare to this target population within a system that is usually fee-for-service, with staff memebers who are used to getting money from patients, and addressing the complexities of the boundaries that we have to draw ie) a dying 6 year old is not eligible for our care... My brain is swirling with issues that I'm learning about, but I'll be online all day if I start sharing too much.

So I'll just give a quick comparison of what I've seen so far, compared to my experience in Uganda. Much like last time, it's incredibly hot and humid and the air quality makes breathing undesirable. The city is overcrowded, very littered, poorly maintained and loud. Electricity is limited and water is scarce. Like I saw before, the amount of corruption within the hierarchy of the powers-that-be creates incredible challenges when it comes to making change; but at least in Uganda there was some government-funded care. From what I've been able to figure out, the healthcare budget was 5% of the annual federal budget in 2008 and was completely absent in the annual budget for 2010. The army takes up something like 50% of the budget, perhaps more. They use "cost recovery" to provide private healthcare and when the government has been approached for funding, they have encouraged health centres to seek international NGO funding instead. So we are working within the system but we aren't really collaborating towards any sustainable change it seems. In other similarities to Uganda, there is a general lack of supplies, overcrowding and delays in health care possibilities. And the culture here, like in East Africa moves at a much slower pace than I'm used to. This is lovely when you are having dinner at a restaurant, making for a very relaxed experience. However, when there is urgency or someone's life is on the line, it feels really uphill to provide help.

The differences compared to my experience last time is that I have physically been coping better; I am adjusting to the heat and humidity and different hygiene standards with greater ease, and knock on wood, I haven't gotten sick yet. In Uganda there were always real shortages in staff, leaving much work to be done by foreigners if they were so inclined. Here there are so many staff members at the centres, you can barely move through them. None of them are officially paid to be there, but they charge the patients themselves. There is no way to distinguish an educated midwife from an uneducated midwife or from a student or cleaning lady, which is pretty wild. (There are also tonnes of volunteer army men, police and traffic control dudes. It's quite hilarious actually; you never know who you're dealing with...could be an official army sargeant, could be the guy next door playing dress-up!) The midwives seem to be less violent than they were in Uganda, which is lovely. They are still quite abrupt with the women and aren't particularly sweet, but it's better. (But it can be shocking to see a midwife reem out a patient because she forgot her healthcare booklet; that wouldn't really fly back home!) There are no HIV programs in place here, whereas Uganda has a relatively a good one. There is no counselling, testing, treatment or prevention of mother-to-child transmission whatsoever! Nobody knows the actual prevalence here and nothing is currently in place to reduce the effects of the epidemic. With how much we know about HIV, it just seems so crazy that we're in 2011 and babies are being needlessly infected with HIV when we know how to make it otherwise. One of the most obvious differences is that most people here are Muslim. There is very little Christian missionary presence compared to Uganda, and the mosque sings sweetly all day near my house!

I could really go on and on...and I will another day... A-M