Friendliness, smiling faces and fist-bumps in Raja

Raja is such a nice place to live.

Walking from our house to the office its lots of ‘how are you?’ and ‘I’m fine’ and ‘Good morning’ (in the afternoon) and ‘Kef?’ and ‘Tammam’ and children asking ‘what is my name?’ and us saying ‘I don’t know your name. Do you want me to guess?’

The kids are great. There are the ones that we see daily who live on the main route between our office and house- like the group of kids that used to run out into the road and demand to be picked up because one of us did that once. That’s the same compound where the kids started screaming, ‘you! you! you!’. I think their mom scolded them though because they don’t run into the road anymore and aren’t as vocal as they once were. Or maybe the magic of our charcoal-ironed MSF T-shirts has worn off for the kids that see us everyday.

Actually that’s true. When I take a different route or end up walking on a path that is new to me, there’s definitely a lot more enthusiasm and even astonishment at our mere presence. We’re more of a novelty off of the beaten path.

Some kids are too shy to reply. Others were clearly paying attention in their English classes. Mostly kids like to shout ‘how are you’. Today as we were moving by car through our neighborhood, we encountered two groups of kids, acting entirely independently, singing or chanting ‘how are you’ over and over again. They weren’t even listening to my reply.

Handshaking is all the rage here, but I’ve become an unlikely advocate of the fist-bump. I don’t do it at home, but for some reason it just seems to be what I need to do here. Why? First of all, if you shake the hands of two or three kids on your way to work, you’re going to get a bit of rice or something wet on there. So I’m saving time on hand washing. Next, people are already sending their hand in for the shake, they look down and ‘what’s this? he’s balled up his fist? but how can I shake it?’ and they have no choice but to reciprocate the gesture.

But the best part is that the fist-bump amazes people and is a cause for laughter and enjoyment. They love this new form of greeting that’s different from the one that they’re accustomed to but not so different as to be unrecognizable. Lots of the national staff at the hospital, the office and the house have taken to the bump too. Again it’s some novelty that the foreigner brings to Raja.

I tried giving fives and high-fives but this ended badly, not tragically but it didn’t go nearly as well as the fist-bump. A few kids loved it. A few kids thought I was trying to hurt them. A few mothers thought that I was trying to hurt their children and they thought that that was hilarious. I thought that the mother’s thoughts were funny too, but overall it wasn’t funny at all.

What I’m trying to get at here is that people in Raja are friendly and it’s a pleasure to continually greet them on our roads and pathways. I get greeted by and do more greeting of strangers here than anywhere I’ve ever been before. I’m fine by the way.

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Discussion and debate

If you’ve read anything in the news about problems or violence related to South Sudan recently, there’s almost no chance that it was near Raja. Rest easy grandma. The retributive inter-tribal cattle clashes in Jonglei, the ongoing violence around Abyei and in South Kordofan, and the newest clashes in a border state between South Sudan and Sudan are reminders that the independence gained on July 9 didn’t mean an immediate end to decades of violence and strife.

Some of the consequences of those years of violence, forced migration, and the population’s inability to live a normal life pursuing its own livelihood are found in the damning health statistics for the new nation:

•    Three out of four people do not have access to basic health care.
•    Malaria is considered hyper-endemic in Southern Sudan, accounting for more than 40% of all health facility visits. (MDG Report 2005, UNDP 2006)
•    One out of seven women who become pregnant in Southern Sudan will die. (WHO 2008)
•    92% of women in Southern Sudan cannot read or write. (MDG Report 2005, UNDP 2006)
•    A 15-year-old girl has a higher chance of dying in childbirth than completing school.
•    Only 6.4% of the population use improved sanitation facilities.

Add this to the estimated tally of the war: 2 million dead, 4 million internally displaced, 1 million refugees. This is only South Sudan by the way; these numbers have nothing to do with Darfur. It’s dire. It’s hard to comprehend.

Looking forward, so much needs to be done. Where to begin? Who should do what? How? What’s MSF’s role?

MSF is a medical humanitarian organization that, let me nerd it up and quote the Charter, “offers assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict, irrespective of race, religion, creed or political affiliation.” To oversimplify things, aid is divided into two categories: relief and development. MSF was founded on relief action and now does it (if I can say so) really well: we are in the middle of civil wars and famines; we are on the scene following natural disasters. What we don’t do is development, which is short for long-term development, sustainable development, bi-lateral aid based development, etc.

So as I mentioned, we’re luckily nowhere near the current violence, but does that also mean that we’re not responding to an acute emergency? Or do the statistics above show that we are? Should a more development-orientated organization be the one here? Or does the lack of medical infrastructure justify our intervention in Raja? It’s true that what we are seeing here is a population in distress that would otherwise have a much more limited access to medical care. The last few weeks has seen an explosion in malaria, which has jammed the pediatric ward to capacity. Lives are on the line. But wouldn’t this justify our opening projects in many other places? What happens if and when we leave Raja?

One thing that I like about MSF is the fact that there’s an ongoing discussion and debate about who we are, what we should be doing and how we should be doing it. So the questions above are open. There’s no shortage of self-criticism and organizational introspection.

For example, my previous mission in Zambia was for a cholera prevention project. After responding annually to the outbreak in Lusaka’s slums for years, it was decided to take preventitive action (mostly chlorinating shallow/dirty wells and undertaking a hygiene education campaign) and then advocate for the government and other actors to follow the actions that we used. Why treat the symptoms and not the cause? It seems logical, but prevention and the activities involved aren’t what MSF does, so we faced some pushback from some MSF members. There was a lot of debate about the project as a whole as well as what activities should be allowed to be undertaken. While at times frustrating, I found it healthy and worthwhile to discuss and compare our proposed actions against the organzational philosophy.

Meanwhile, in South Sudan, things are still hanging in the balance. Things are calm in our neighborhood, sure, but at the moment there’s no shortage of places that aren’t. The reality is much improved, but still precarious. Raja, population 26,000, is reportedly made up of 90% returnees. 90%!? That means that only 10% of the people now living here were also here during the worst years of violence. What would this town look and feel like with only 2,600 people in it?

It’s hard to imagine. Maybe the same way that it’s hard to imagine us not being here and not treating the women and children that so desperately need us.

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The end of Ramadan, the beginning of beans

Today we began the celebration of Eid ul-Fitr, which is the feast day marking the end of Ramadan. Well, I say ‘we’ began the celebration, but really I didn’t celebrate anything. It’s the national staff members that are now on holiday until Monday and the Muslims in the community that are celebrating. Technically we internationals did have a holiday today, but we worked anyway. What was I going to do, sit around eating beans all day? I worked, took a long lunch break to read a bit, and went back into work. It was a nice and easy day on my side. The medical staff in the hospital, on the other hand, is quite busy. Our pediatric ward has been crazy full with cases of malaria. It comes with the rains. Those staff members don’t get to enjoy this long holiday.

Ironically enough today, as the Muslims end their fast, I was really hungry. The woman who usually cooks our lunch and dinner had the day off of course. Also Mohammed’s small shop between the office and the house was closed, so I only had a piece of bread for breakfast before finding a small shop open in the market this evening where I bought some crackers. Luckily when I arrived home I found that our Field Coordinator Grigor had sought out some food and cooked a nice meal for us, including his famous beans*.

The downside of this holiday is the delay of some of the works around the hospital that I would have had going on; the roof for the new kitchen, windows for the new laundry area, latrine construction, lots of digging- so much digging has to happen. I should write a post on the digging later. Whatever though, the delay is not a big deal. The upside is that I have time to do some of the administrative stuff that has to happen this week; reporting, budgeting, etc.

*Beans, so much about beans, where to begin? Actually, over dinner last night I was talking about how I hadn’t been a big eater of beans until I came here. Now I love them. That’s #realtalk. It’s a funny topic in the house though as some people aren’t really into beans while others… are bean pushers. Is that fair? I don’t know, but when we have visitors from the capital they are always treated to stories and debates about ‘the bean incidents.’ I could write a whole post about beans. But will I?

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A few tears

It all happened so fast; I froze. I certainly didn’t know what to do. The kid was completely shocked and confused. It could have gone either way for him, to laugh or to cry, but after the second wave stuck his feet and the little splashes hit his shins, it became obvious that he was going to begin crying. It was a matter of seconds until that got going and there was nothing that I could do. His older brother laying safely on a bed and laughing at him, the water sloshing up against his feet, his hand frozen holding a ball of fried dough halfway between the plastic bag and his mouth, he simply wasn’t able to understand what was going on. It was too much. The kid was just stupified. The tears did come, just after his face scrunched up and he started wailing.

What was she doing!? If you asked her, she was simply mopping. From my perspective though, her technique seemed a bit off. She pushed the water across the floor straight between the line of beds and the wall, ignoring the fact that a person was in the middle of that aisle. Then she pushed more water straight at the kid. As we know this now infamous ‘second wave’ pushed the boy over the edge. Becoming annoyed with the crying that she’d caused, she snatched him up by his little arm and plopped him onto the bed, next to his brother who was delighted because in addition to laughing at the crying he could now also get at the snacks at the end of his little brother’s now possibly sore arm.

What a stroke of good fortune for the older brother. What dismay and very guilty amusement for me. Ever since she’d started sloshing the water onto the feet of the boy who stood in her way, I’d wanted to do something but couldn’t. The distance, language barrier, and full hands prevented me from any action. I had a front row seat for this little episode but couldn’t help in avoiding tears. I didn’t even get one of those fried dough balls.

In a funny coincidence, one of the reasons that I was there in the ward was to ask nurses and clinical officers about what they thought the cleaners should be doing at different times during their shifts and what could be improved in their performance. So in a way, as I’m responsible for the cleaners and their work, this was just the kind of scene that I needed to witness.

To be fair I should say that kids are crying all of the time at the hospital, and usually for better reasons; getting a blood prick test, getting an injection, having an IV put in, though I saw one kid freaking out because he didn’t want to stand on a scale- his mother laughing at him. So this one crying about a little water? He was kind of being a baby; he’s a few months older than a baby.

To continue being fair, the cleaners are nice ladies. We speak through our Arabic translator of course, but there are smiles, attempts at hand gestures and some laughs in our meetings. They don’t make me cry. In our initial meetings they have been very open to the idea of participating in trainings, reorganizing their routines, and have given us good feedback about where they see needs for change. It’s not easy to come in and try to change the ways that people do things, but its necessary. Actually, last week was huge for us in the cleaning department. We reorganized the colors of the buckets used for different types of waste and cleaning activities in the wards. Yeah I know! Exciting! OK, not that exciting really. Organizing buckets isn’t the kind of thing that sounds that cool, but as I’ve prowled the wards these last few days and seen the right colors in the right places, I’ve been pretty chuffed (Ammar, I used chuffed!).

In our in-patient pediatric and maternity wards, we have a three-woman 24-hour rotation of cleaners, where at the outpatient ward and operating theater we have only daytime shifts. But despite the cleaners being on duty for 24 hours, the in-patient wards aren’t clean enough yet. There’s room for improvement, let’s say. We have guidelines for what needs to be cleaned, how often and with what kind of chlorine or cleaning solutions. These need to be retaught, made a part of the daily practice, and monitored.

One thing that has improved but isn’t perfect is the burning of charcoal in small metal boxes in the back hallway of the pediatric ward to heat milk for the kids. It sounds mad, but before MSF came here they were burning it daily inside of the buildings and might have done it next to the kids beds for all I know. Apparently we cracked down on this practice months ago, but I came across the little BBQ alight inside of the back door once. I brought this up with our hospital log(istician) and he shrugged his shoulders and said that it’s culturally unavoidable. He said that they cook inside their tukols (brick and grass huts) at home sometimes and so probably don’t see the big deal about a little smoke inside of the ward. Ugghhh. No, this activity will not stand. Local culture has to give way here.

The timing of cleaning activites seems to be a bit off too, like flooding and mopping the entire ward just after the medical rounds have started and when little boys that don’t like their bare feet getting wet are standing around ready to start crying. That’s not the best timing. So of the improvements that we’re working on with the cleaners, one of the most critical is a more organized routine that fits with the medical activities. This of course needs input from the medical side as well as some more direct observation by me. Also, it appears that a few tears are going to have to be shed along the way.

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First week in a one-week-old country

I’ve spent most of my first week in the MSF office in front of my computer, the same computer that I was sitting in front of a week earlier at my parent’s house near Chicago. Five flights later and the scene has changed quite a bit. The airports and planes became smaller and smaller until I buzzed into the town of Raja on a World Food Program single prop. The dirt runway is about a block from the office, which is a football field away from the hospital where we’re doing the bulk of our activities. While the planning and research that I’m doing on the computer is critical for my work, I’m looking up from it and getting away from it whenever possible, curious to get a grip on what’s going on, excited to get my hands dirty.

As a watsan (water and sanitation… guy), I’m charged with overseeing things at the hospital having to do with water quality and quantity, latrines, hygiene, vector control (mosquitos and such) and health care waste management.

The hardware side of things should be straightforward enough; install the pipes, dig the pits, build the structures, smile and cut the ribbon. With this being the bush, this isn’t the case. Supply, supply, supply is the difficulty, because of our remote location. The local market is a scene. I love it but it has nothing to sell to me for my work. Even for food it simply lacks. Pipes? Not one. Taps? Sorry, no. Cement? Maybe, who’s asking? Onions? Yes, but they’ll cost you. Onions are like gold here. Potatoes aren’t even available anymore but we have a giant stash in the kitchen. There’s no wine… it’s a genuine dearth.

The software side is where things become more complex and challenging for a watsan. Software is people- training them, building for them, or maybe even listening to them. People are complex enough, but even more so when they don’t share the same language, receive the same cultural truths, or shop at the same Whole Foods locations. How can I design latrines for people when I’ve been in their country for less than a week? Which is a coincidencce as their country was only a week old when I arrived.

As much as I’d like to think that my job is the most important (psst: it totally is), we’re a medical organization and I’m actually here to support the medical activities. Our energetic Argentinian doctor showed me around the hospital. Building by building, room by room she pointed out the inadequate number of water points, the deficiencies of the waste management system, problems with existing structures and ideas for future ones. She did all this while greeting men and groups of women and children with the energy and efortlessness of someone running for public office. “Salam aleikum. Tammam?” “Tammam” They replied with smiles. She did everything short of kissing babies, although I think she did save a baby’s life. Our last stop was the pediatric ward and just as we were wrapping up our tour, we were interuppted with a medical issue that she had to deal with right away. This is what the whole thing seemed like as it happened:

‘So, a drinking water stand here and a handwashing station over there?’ I say, squinting and adjusting my glasses with the eraser of my pencil.

Over her shoulder, as someone hands her a baby struggling to breathe, ‘Sorry, I have to hook this baby up to the oxygen machine, set up the IV, advise the national staff on the baby’s treatment plan for the coming hours, get someone to run and tell Wilson to turn the generator back on so we have power to run the machine, use a translator to communicate to the mother what we’re doing for her child.’

‘Oh no problem, so I’ll just stay right here and make a little map of the ward and draw little dots for handwashing stations and squares drinking water stands? Cool, I’ll just be here then.’

Of course all she really said before jumping to action was, ‘Sorry Emmeeeett, hold on.’ But after days at my desk working on the technical stuff, examing the stock in the warehouse and inspecting the watsan facilities around the hospital, it was very nice to get hit on the head with this very medical experience, to be reminded of what we’re actually doing here. The whole whirlwind tour with her was exactly what I needed in order to connect the proposed watsan improvements with who I’m doing it for and how it should be done. Anyhow, I still need to do more to engage the national staff- from doctors to cleaners- as well as patients on their thoughts regarding my work. Then we’ll have to work on getting the right parts out here. It’d also be cool to get some wine.

That’s all for now. Going forward I’ll try to shed some light on our work and on the situation in the rural, beautiful, and until now quiet Western Bahr el Ghazal state of the newly indpendent Republic of South Sudan. I’d appreciate any comments and questions you might have. Until next time, I’ll probably be at my computer.

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Emmett Kearney is a water and sanitation logistician from Chicago. He obtained his MSc at WEDC-Loughborough University, studying water and environmental management for developing countries. He began work for MSF in Zambia, on a cholera prevention project. Before that he worked for two years on the Thai-Burma border. When not in the field, Emmett might be with friends in Chicago or enjoying Thanksgiving in July with his family.

Posted in Biography, Healthcare Provision, Logistician, South Sudan | 4 Comments