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...
