Make-do/can-do

The chaos of getting 22 people off in 7 cars to 7 different destinations as close to 8 AM as possible did not materialize. Our Ghanaian colleague Philip had been fretting over getting this right, not an easy task, and then everything was right. At lunch time everyone returned and the field visits had been completed without a hitch, with spirits high. There had also been some bonding across organizational divides; there is nothing like sitting together in a car going over bumpy roads. It reminded me of a field visit I made with a bunch of family planning professionals from all over Francophone Africa in Benin. We travelled over bad roads for 700 km, from early morning to deep into the night. We sang songs for hours, told jokes, changed tires and pushed the car out of mud; we became friends for life!

I accompanied two gentlemen from the ministry of health and we were  expertly chauffeured by driver Valentine over roads that had lost their hard top here and there. Although our destination was not far, it took us exactly an hour to get to our destination. We were warmly welcomed by the midwife in charge, just outside the Labour Ward where some hard work was being done by two women who had reached their term. No husbands were present – labor, even with an extra ‘u’ is women’s work.

Over the next couple of hours we chatted with various employees and explored the buildings and rooms that were part of the health center. The senior leaders were told to present themselves as students, counter cultural for sure. There had been much concern before the visit about whether this was possible and shouldn’t we surprise people. But none of these fears came to pass, as I knew from experiences elsewhere.

The health center consisted of the main block with wards and consultation rooms, a block of dilapidated staff quarters, an incinerator, two containers that houses the generator and the ambulance, a block of rooms for specialized services and something that was referred to as the ‘new’ building, a large unfinished structure in a corner of the compound. Work had started some 8 years ago but they had run out of benefactors or the benefactors had run out of money.  Inside it did not look like a new building anymore.

A matron who had been taken out of retirement had settled into one corner of the building overseeing a makeshift recovery ward. The ward has two beds, one covered with two crib mattresses instead of an adult mattress, a bench and a crib. ‘It’s not enough,’ she said. Sometimes she has to ask the least sick person to move over to the hard bench. We were all inspired by her commitment, passion for her work, concern for the community and can-do attitude. She surely was able to make something out of nothing. Asked about her retirement, she answered that she was too good and too strong for that and that she plans to continue working under contract as long as she can.

Throughout our tour the accountant accompanied us, pointing out the places where resources would make a difference and places where they themselves had made a difference in the absence of a response from their own employer, the government of Ghana.

At the family planning clinic we found the nurse talking with one of the outreach workers, a young man who does vaccinations as well as HIV/AIDS outreach. We asked the nurse to teach our driver how to put on a condom. He was a good sport and demonstrated at the end of the lecture that he had understood everything well, from hand washing to opening the package and rolling the condom down on a wooden model; all this done with great care and clarity and a good dose of humor.

On our way back to the hotel we stopped at a tiny community health center staffed by community nurses. We learned much about the reluctance of the (very poor) local people to be referred to the next level health center and how this has led to true telemedicine: the nurse in charge calls the physician assistant, who is the person in charge of the referral health center  (the one we had just visited ) who coaches her trough his cell phone on how to give care that he would have given. It is not ideal but she learns from this and the patients benefits; another form of can-do/make-do.

I interviewed three young community nurses who are entering their second year after 3 weeks of practical work. They had just returned from their community outreach rounds, checking up on the vaccinations of babies and mothers. Their eyes sparkled and their uniforms were spotless but brown; the coveted white uniforms are not for them until they pass next year’s exams.

After lunch we compared notes among the seven teams, using appreciative inquiry as our approach: what had they seen that was inspiring, touching, surprising (in the positive sense) and life-giving (literally and figuratively). What we heard stood in sharp contrast to the supposed incompetence, low morale, mediocre care, inertia, drug supply problems and poor management that we are usually being told about by the top people in the ministry, people like the ones  we had in the room.

We were encouraged by the interest and enthusiasm from our participants; there is no more coming and going and, aside from things like punctuality, everyone is fully participating and deeply involved in the program.  I provoked them around the punctuality issue. There is much denial about their own behavior and they are rarely confronted, except by their bosses, who probably don’t manage themselves very well either. There is also much inertia and little sense of collective responsibility. A few individuals are proud, and want recognition for being on time and ‘sticking to the norms.’ Yet there is no action to make sure their whole team is present, even after several hints. Although Americans are culturally considered individualists, and Africans collectivists, when you look closely you see that the educated elite has drifted far afield from the collective sense of duty and responsibility, may be not in their words, but surely in their actions.

We ended the day with two exercises, one called the Helium Rod, which we fabricated out of flipchart paper, and the other about shared vision, using a gadget that we also constructed out of material found locally. Experiential exercises are still a novelty here. It is one place where we can put a mirror in front of the participants and show them what they actually do, as opposed to what they say they should be doing. In a place where senior people don’t ever get direct and honest feedback about what they should be doing differently, this is the only way to confront people so they can see what they need to work on. Intellectually they buy this, but there is a sense of impotence when it comes to action.

Today the rubber will hit the road. In a reflection about the effect of the appreciative inquiry many expressed concern about it being a bit artificial and not contributing to the solution of problems. The problem-focused approach to work and life is so deeply entrenched, and so pervasive that it has become embedded in their very cells and doing anything else feels wrong. We told them we will get to these problems later but first wanted to establish a solid foundation of knowing what is going well so that this can be supported, enhanced and extended.

Today we will focus on their challenges. We will put them to work, in teams, on analyzing how they can remove obstacles they observed in the field. I have a premonition that they will find ways to push the responsibility for solving these problems further up the chain, thus reinforcing the practices that firmly keep in place the roadblocks that everyone can list in their sleep and that have been identified in countless reports for as long as I remember but that no one feels empowered to tackle.

Teams

The trip I hoped to make to Kabul with Axel, in just over a week, seems more and more unlikely and the limbo continues. I try not to get too upset about this, although I am disappointed. I have stopped to look too far ahead (since there is nothing to see) and instead am focusing on the work of now. It makes me forget the disappointment as it connects me to exciting projects and wonderful people around the world.

I received the most encouraging news from my team in Cambodia which has managed to get government health facilities to make special efforts to reach out to youth, with a focus on reproductive health. The 26 or so government officials who are the first to participate in the leadership program were rather skeptical at first. Others were also skeptical about them and had their doubts that anything would change. The health facility managers set what seemed fairly un-ambitious goals for their teams – but it seems they have been surprising everyone, including themselves, and surpassed these goals.

The senior leadership work in Ghana that appeared to be stuck for the longest time in the initial planning phase has come unstuck. Now it requires the alignment of schedules and a dates. And that’s where I bump into my uncertain future.

Another piece of work like it, concerning senior professionals as well, is in the planning stages for Central America. I am helping my colleague Diane design a process for getting senior leaders focused, moving and more confident in their ability to function well as a team and fulfill their oversight role for major investments in health programs. She will do the actual facilitation since I am not a fluent Spanish speaker, but we fantasize about doing it together. Given all the scheduling challenges, this is highly unlikely.

Last night we attended the annual meeting of the Manchester Historical Society. The average age of its members is probably about 65. Although on the young side of the median, with enough grey hair, we blend in nicely. There is always wine and an impressive buffet of finger food before we start with business. This helps with the socializing although I always manage to introduce myself to someone with a mouth full.

The business of the Society is conducted in no time adhering to the letter rather than the spirit of parliamentary procedures. This makes the business meeting a breeze. The last piece of business is always a motion to ratify any errors and omissions of the executive board, which we gladly did.

The highlight of the annual meeting is always a speaker with something interesting to tell us about the place we live. This year it was a gentleman who had written a book about Cape Ann. He told us many great stories, accompanied by slides, of the famous people who resided here, their houses, their houseguests and friends, and their writings about and paintings of Manchester, Essex, Rockport or Gloucester.

Talks

I had my first formal interview for the position in Afghanistan. Talking about the work, the responsibilities, the challenges made me even more eager to get the job. I have to be careful not to get too invested in the idea because there are others who want the job. I figured that my strongest competitor would be an Afghan-American woman with tons of executive experience if the decision is made that an outsider rather than an insider to MSH is preferred. It’s funny how, when you are at a fork in the road, so many people seem to know what lies ahead around the corner.

My French-speaking colleagues and those who want to perfect their French have initiated a one-a-month French-lunch-about-a-topic at work. Yesterday’s lunch was facilitated by Ashley, a spirited young woman whose enthusiasm overcomes any hang-ups one might have about not speaking French perfectly. She had picked the topic of HIV/AIDS and prepared a glossary of terms in English and French. I was very impressed.

She asked us all to talk about what we had recently learned about HIV and AIDS. We went around the table. Our group included four young American women, one from the Middle East and two African males, one a doctor from Cameroon and the other an IT expert from Senegal.

The one doctor in the room was by far the most knowledgeable, as he should be, and I discovered he is also a great teacher. We talked about facts and perceptions, male behavior and got an illustrated lecture about the female condom. I could show what it looked like (no one had one in their pockets) with the pictures I had taken at GHC earlier this week and placed on facebook. As we checked out my facebook page we could also see who of our colleagues were on facebook while at their desks.

While I had my hair cut at the end of the day, I listened to what happens to a woman who is financially and administratively illiterate and trusting a husband who should not have been trusted. I suspect this story is played out in shocking numbers around the world. She is discovering that she signed for 2nd and 3rd mortgages on a house she thought she owned and is hundreds of thousands of dollars in debt while at the same time replaced by another who has taken her place in the heavily mortgaged home and conjugal bed.

Her image of an ordinary marriage, couple with teenage son, has shattered like a mirror into a thousand pieces. I can practically see the reverberations of this monumental source of distress across the network of relationships each of them are in.

I remember telling her at least 10 years ago when the kid was young and the husband (maybe) not yet cheating that she should teach herself about the routine financial and administrative transactions that happened in her household so that, if she found herself alone, her grief would not be exacerbated by this not knowing. I also remember her response, which was one of surprise and indignation – the situation was simply unimaginable to her. We both remember the many silly (and often expensive) purchases she made over the years.

I think there is a good case to be made about educating young girls and boys to be financially literate before they leave school. It would prevent countless women from sliding into poverty, as she is now doing. The wakeup call was the first visit to a food pantry. She’s still in shock and there is no visible exit out of this nightmare.

International health at home

My attendance at the GHC conference was very short. Everything was just warming up when I left. Still I got to listen to some very creative and inspiring speakers who use various internet and mobile technologies to promote or protect health. This is how I learned that of South Africa’s 45 million people 43 million have access to a mobile phone. I also heard the terribly sad story about how mothers in Nigeria who bought teething syrup laced with anti-freeze fluid unwittingly killed their babies. On the other hand, amazingly creative experiments are going on in Ghana to outsmart the makers and sellers of drugs that either don’t work or that kill. Listening to these stories makes you realize that we have, collectively, the ingenuity to constantly outsmart each other, for good and for evil.

The best part of the conference is the exhibit hall. If you like candy, pens, stress balls, pins you can stuff your pockets full, with or without listening to sales pitches. Some connections with global health are tenuous – there are travel agents and Toyota land cruiser salesmen.

The Gapminder people were there with their amazing displays of world population data. They demonstrated an electronic table top game that tested your demographic data knowledge for the countries of the world as if you were playing blackjack or poker, with chips and all.

But the best exhibit was from the condom people who took up an entire wall. There was a lube tasting bar, condom pin making, an informative video about condom making and testing (like filling them up with 32 liters of water – why that much, one wonders) – a manikin dressed in an outfit entirely made up of condoms, African cloth baggies to hide your condoms in and more. The playfulness is exactly what they want as total strangers strike up conversations about topics that are usually taboo. The money for these displays and this creativity comes from the UN, not the US government – not a surprise.

I arrived early at the airport. My taxi driver came from Ethiopia but seemed not very eager to talk about his country that I am to visit soon. He left 24 years ago when it was not such a nice place. At the airport I was served my order of pretzels by other Ethiopians, recent émigrés who were more enthusiastic about their country. The cost of a few pretzel sticks, a mustard dip and a pint of water would have provided an entire feast for countless people in their homeland.

I was early enough to catch the 3:30 flight but, despite my 425 dollar ticket I was not allowed on unless I paid a penalty for 50 dollars – which I stubbornly refused ‘out of principle’ only to punish myself with a considerably longer wait at the busy airport.

I arrived home to find the entire family, including Sita and Jim around the table and everyone commenting on the bug Sita had brought home from her travels. Since she looked a bit wilted we looked ORS up on Google and prepared the proven practice of home-made oral rehydration solution for her. Just before going to bed we watched a documentary about the Taliban nightmare in Pakistan; not surprisingly it produced some bad dreams.

Back on the rails

A series of accidental things happened yesterday, such as peter Block’s book the answer to how is yes practically falling off the bookshelves while I was looking for a present for MP’s birthday in our lending library; and some emails from Joan about recent blogs about senior leadership.

I think the universe provided me with those resources to get me out of my funk and my moping about yesterday’s meeting getting off the rails. With those I was not only able to consider my own contributions to it but also what to do different today.

I have gotten very sloppy about applying Christopher Alexander’s pattern language – which I reformulated years ago to apply to groups, and usually pay attention to. I did notice that the room we are holed up in each day is messy with very little light coming in through the grimy and barred windows, and piles of paper and debris in the corner. It’s a bit of an energy drain.

It does not have to be a perfect room and some features cannot be changed but any place can be enhanced, spirit wise. Yet I left out my usual colorful quotations and poems on the wall and I disconnected the music after I asked my colleague whether I had the right music. When he said I had not I concluded that music was out. This morning I learned that music is fine. Not everyone has the same opinions about music and just asking one opinion may get you the wrong advice. I had gotten lazy. As a result there was no spirit in the room yesterday and the result should have been predictable to me – may be not to others – but I should have known better.

So today I am in repair mode. I asked Dr. Ali to play music that would be acceptable. I asked my Afghan colleagues who are steeped in local poetry to get me some poems that lift spirits and I am looking for pictures of the Afghan men, women and children that justify the existence of this department in the first place. I am usually better prepared. This kind of last minute grasping at straws is not good for the soul and dos not quite achieve its intended effect – sloppy work is never good but in this case better than none at all. All I managed to get going was the music, and that only for awhile.

Since the official swine flu man is not available the group decided yesterday to educate itself. The family planning director volunteered yesterday and presented what she learned – it’s called self help and it is not all that difficult.

The remainder of the morning session is not mine and I watch it unfold while trying to figure out what plan it follows. I have translators around me and can follow it somewhat so i can steer things a lilttle bit from behind. The rest of the morning consists of a mixture of interventions in Dari and English, with several people taking the lead for this and that and me sitting sometime on the side lines and sometimes standing up front.

We talk about the specific challenges at the top. In private people say different things than in public. In public the problem is not with them but with their bosses; I challenge them on how they can learn from mistakes when they don’t get honest feedback. The women shake their heads up and down, the men sideways – they claim they get honest feedback and learning is easy and straightforward. They are either not seeing the dynamics around them that interfere with learning or they are in denial. I don’t really believe them – just from the way they react to my challenge I can deduce that challenging them from below is pretty courageous, or stupid, or both.

We end on a higher note than yesterday, receive positive and negative feedback from the 8 people who are still with us (most of the women, less of the men). I have no idea what the others are thinking, the ones who left – and whether they left out of frustration or because they were called out.

When lunch arrives all the women leave with their fast food trays. I seek a bathroom but they are all locked. It is weekend at the ministry as of 1 o’clock and the place is deserted. One of the female participants, as a director, has her own toilet stall (one of two on the ground floor). It has its own separate lock. She cannot open the lock and I tell her I’ll use the dirty public stall but she won’t have it. Eventually we get the door open and I step into a stall that is comparatively clean, with toilet paper, running water and a lock, none of which are present in the other stall – mind you, we are talking ministry of health, central headquarters. Of course, what can you expect with mostly men in charge of buildings, designing and building them? I am confident that all this will change when the women are in charge.

Afterwards I am invited to eat with her and another female department chief. The scarf is dropped and intimacies start, even though there are two male secretaries around, but they pay no attention. I hear about the utter frustration of having to prove oneself as a boss, being female, despite superb credentials. It’s a daily struggle for the women in leadership positions who are confiding in me. They are undermined, ignored and bypassed routinely. She receives some technical advice, but it is not about the things she really needs: how to manage recalcitrant or arrogant men who don’t accept her leadership and seem to want to see her fail. I can tell she is hurting deeply. I tell her about pioneers and that she is cutting a path through the jungle – yes, she says, indeed, it feels like a jungle. These women are pioneers, maybe not the very first but closest to the front where the battle lines are still drawn. It will take a few generations, at least I suspect.

Back in the office we are lectured by MP about swine flu – I am starting to become an expert myself. Then I hang around the office for a couple of hours waiting to see if I can meet with key people but they are all busy in other meetings. I sketch out the remaining week of my work and see that every minute is booked in one event or workshop or meeting, most away from the office. This leaves no or very little time for sitting together with my colleagues to debrief, explore, plan, give and get feedback. I am beginning to wonder whether I should postpone my departure.

Centrifuge, humble pie and fruity refreshment

We are in the basement of the ministry, five women and eight men. This is the first of many suprises to follow. Imagine that, more than a third of the team consists of women. I don’t think I have seen this before (in Afghanistan), especially not at this level. Aside from the electricity being on 24/7, this too is a sign of progress, much better actually. I congratulate them. Some men say it is not good enough, and that they need more. Bless them.

The top leadership of the general directorate is not with us – called out to solve a crisis in one of the provinces and then in another. This is the bane of senior leaders’ existence. In hindsight we should have cancelled the event because of this. After all, how can you build a team when the head of the team is not there?

We try to make the best of this situation by focusing people’s attention on the crisis that is around the corner (swine flu). People usually don’t deal with crises that are around the corner because the ones that have already rounded the corner and are in full view demand all their attention. They pull everyone away from the center, each director doing his own thing as best as he (she) can, with always the risk that action in parallel creates new problems that could have been avoided when done in concert. People know they should be doing things differently but there is a sense of frustration and powerlessness to change this dynamic. I had an experience of total immersion in this situation to remind me that things seen from the inside are always more daunting than when seen from the outside.

We wait for about 45 minutes before people trickle in before we start, without anyone’s blessing. That is not how things are done here. I am going along with Harrison Owen’s principles that say ‘whoever is there is the right person’ and ‘it starts when it starts.’ Later in the day I come to doubt the former of these two.

My Afghan colleague is facilitating the event because when I talk in English everything needs to be translated for a few of the participants who cannot follow me. Also, I find that when I talk everyone becomes very quiet. So doing the event in Dari seems better – everyone is very animated and engaged. But since I don’t have anyone who can translate I have no idea what they are talking about. It’s a leap of faith I have to make. It’s a leap that I usually make with some confidence. We went over the design in the car driving across town and my colleague says he is fine with it and with being the solo facilitator. I have seen him do this many times and know he can do it; he is a good facilitator. He is comfortable challenging people in ways that are not commonly practiced, especially at these levels.

I watch him as he talks about vision and influence. Everyone is listening spellbound. For a few this is not new, yet they are attentive as if this is the first time they hear about the topic. For others this is entirely new material.

After that I am not sure where things are going because the temporary translator I had by my side is called to be a note taker. It’s a perfect example of planning one thing and then another need arises that pulls someone off one task and puts him or her on another. In between his writing I catch a few translations, forcing him to multi-task and pay attention to me, the facilitator and to what everyone is saying. This is the challenge and this is the work.

A young female doctor who is a trainer at the public health institute joins us. Her name is Shakile which I am told means shapely. She facilitates some of the conversations and I coach her form the sidelines. I notice when she facilitates that all the men talk right over her. She does not stop them and it becomes a little chaotic. As a young woman she cannot easily confront the group, especially the male directors, and ask for only one conversation at a time. Later I hear that her facilitating was bothering some of the older men. I never quite know whether we should give in to this wish to remove all younger females or let them get used to this because eventually they realize that facilitating is not the same as being a resource person or expert. The young woman has good instincts about facilitation and is thirsty for coaching like a sponge.

The design is slipping away as we start to zigzag, following comments from participants that first take us here, then there. I can tell people are starting to lose sight of the path, that wasn’t very clear to begin with. First it is body language and then they actually speak out.

I am afraid we may have lost some credibility – the design is too loose, too fluid as if we don’t know what we are doing (and maybe this is true). I feel rather helpless on the sidelines, not being able to engage directly with the participants, nor understanding the logic of the emergent design. I call the office and ask for a translator, dedicated to stay by my side for the entire day, with no other task than helping me understand what people are saying.

The executive assistant of our project director shows up within half an hour. By now we are fully off the rails. Here, as with the previous team we worked with, the earlier communication with one part of the ministry contributed to the confusion as they were led to believe that this was a training course. We are experiencing first hand this communication problem everyone talks about and the consequences of having centrifugal senior leaders.

It is good that I expected surprises, but there are more than I expected. Over lunch I find out that the session is supposed to stop at 2:30 and I am beginning to wonder about the utility of another day with this team. Can we put the process back on the rails?

We leave with our heads bowed down. It is a humbling experience to fail like this. People are coming back tomorrow morning. I feel the pressure to have something to show then, in exchange for the time they will have invested in this confusing exercise. Invest in what? We made little progress with the swine flu exercise because the chief expert in the country is meeting with someone from our own project while we wait and wait, and finally disband. This is of course rather embarrassing because it speaks of our own miscommunication and mal coordination – a symptom we are supposed to treat.

I arrive home before anyone else and get myself a softdrink in order to – as per the advertisement – ‘sink myself into fruity refreshment!’ – it’s just what I need now.

Good grief

I dreamt that I was up against organizational rules and being choked by an unsympathetic bureaucracy in a deeply disempowering way, leaving me feeling utterly demotivated and ready to quit. The rules were silly, cooked up by someone who had no idea what they were talking about, yet enforced as if the future of the company depended on their rigid implementation. My noncompliance became a disciplinary issue and eventually a fight. But I did find some kindred spirits, ready to fight back.

I know exactly what the dream was all about. It was a continuation of a talk that Maria Pia and I had last night about travel – a topic that is, for us frequent travelers, a source of endless stories; nice stories, horror stories and causes of great grief. I Iearned that other travelers have come here on tickets that can be upgraded or changed in ways my deeply discounted ticket cannot. The tickets were more expensive, sometimes more than three times as expensive – and sometimes they are issued directly in business class. How that is possible appears to depend more on people and their attitudes than on company policy.

The conversation turned my disappointment about not being able to route myself back through Beirut, to be there with Sita (since I am practically flying over her head), into anger. I think if someone had offered me a job right then and there I would have taken it. It is the inequities that bother me – if everyone is told to fly on the cheapest ticket, I would be at peace with it. But I learn that this is not the case.

Enough of this self pity. Yesterday was an exhausting but satisfying day. We did manage to have a significant number of people from the policy and planning general directorate in the room. Of course we women were outnumbered by a factor of four – but this is to be expected; especially in a directorate that has a lot of powerful departments that each handle enormous amounts of money (grants, construction, finance, etc.)

Despite the usual assurances that the event could be facilitated in English (people at this level are expected to speak English with ease), we quickly fell into Dari when I noticed that the conversations were more spirited in Dari than in English. This meant that my colleague was facilitating and I watched over our emergent and fluid design from the sidelines, sometimes whispering suggestions in his ear about what to do next. I prefer to ‘dance’ with the participants directly instead of being a choreographer, but until I master the language, that is the role I have to play.

The design was derived from a medical model: diagnostics to see how the circulatory and other organizational systems were functioning. Although we had hoped to get to at least a shared vision, the diagnostic took the entire morning. It was the first time ever they were sitting together like that and talking about their work, their accountabilities, their collaboration and their mandates.

My colleague did his job as facilitator as well as an insider (= Afghan) can do (this means he cannot question and push back in ways I can do, as a naive outsider). He asked the two young female doctor/trainers to contribute bits and pieces here and there that warmed my heart. When the third female, a recently hired female doctor who will advise the chief, and who is used to run an entire organization, was asked to take flipcharts home to type them up I intervened and pushed the task back to the chief, for his assistant to do. I don’t think he was happy. We have had one other female advisor placed with a government department and she was quickly turned into a secretary. If she doesn’t watch out, the same fate awaits her.

Despite assurances that the team was willing to work through lunch, once lunch was served the work was done. We tried to resuscitate the lethargic body after lunch but soon realized it was in vain, the energy gone and life intruding again. To our great delight the group had found the exercise useful enough that they wanted another session before I leave. That was better feedback than any verbal comments on the session.

This is a group of people (men) that is pulled in all directions and super busy. That we found a slot of 3 hours that (most) everyone can attend is a miracle. The only regret was that several of the department heads were absent, having sent their deputies or other underlings instead. I hope we created enough of a buzz that they’ll show up next time.

Suddenly I was pulled out by my colleague who practically dragged me to a large hall, rushing over so we could be present at a graduation ceremony. What I learned along the way is that a group of 250 public health students had gathered in the large auditorium of the ministry to receive their diplomas. What I had not realized (and no one told me) is that they had wanted us to be there at the ceremony and speak and that they had dragged out the ceremony, waiting for us for a long time – while I was eating my lunch, oblivious that around the corner these 250+ people were waiting. As we entered the auditorium I asked Ali whether I was expected to do anything (like a speech) – hoping I was not. But when I was whisked to the front stage and given a microphone, I knew.

I wondered what it was like to be a celebrity and always having to give such impromptu speeches and concluded that the worst part was speaking to people I had no relationship with; a few would be OK but 250?

Since they had learned about leadership and management I was presented as the guru from the US and had to improvise a speech befitting a guru. Once again, I wished I could have thrown in some Dari, but I am not there yet. Besides, I am discovering over and over that when I pronounce the words, thinking I say them exactly like an Afghan, they don’t understand and look at me blankly until I show them the words – then they say, ‘oh, you mean…?’ (saying what I think is exactly what I said); so better not getting into such an awkward situation.

And now a full two days of staying home.

Easing in

My first day of work is a half day. Saturday is a work day for the government but not for my colleagues. Since their counterparts are in the government they often do end up working 6 days a week.

My colleague picks me at my guesthouse and we drive across town to pick up his boss before heading to the Ministry of Health. Security is enhanced and people can no longer walk into the place unhampered. Sandwiched in between my male Afghan colleagues I walk right past the guards who stop us to check my bag. They let me pass through when one of my colleagues said that I was not with Al Quaida. I must have looked like a low risk between the countless turbaned Afghans who would all have been frisked had this been an American public building.

We meet with our counterparts of the Institute of Public Health who had signed up for several virtual courses which I am asked to explain. I do not know the particular course they signed up for and that starts next week but tell them about our virtual courses in general, with the message to over-communicate rather than under-communicate with the facilitators, having been a facilitator with a few too many under-communicating teams in the past.

Next stop is the institute for health sciences where paramedical, nurses and midwives learn their trade. I did not expect to see so few women in an institute that trains students for what I consider female professions. But I could have known. We see a few young female students at the end of our visit. I am told that now it is 100% better than at the Taliban time when of course there were no women at all in the building. There are jokes made about that time but I cannot understand them and no one translates.

We meet with senior faculty to talk about introducing or strengthening management and leadership as topics in the curriculum. It is entirely neglected in the midwifery curriculum because of the haste to churn out large numbers of midwives and to cut the program from 3 to 2 years. Whatever little there was of management preparation (and they do have to manage once on the job) was considered a luxury that could be discarded. Yet when I query them about their own clinical experience they all have stories about costly mistakes that were made because they weren’t prepared for the management and leadership tasks on the job.

The meeting is entirely in Dari and reminds me of the need to learn that language, even though it is kind of a long shot, given how infrequently and briefly I am here. Yet, every new word I learn contributes to my understanding which is now entirely dependent on translations from my colleagues. Their short translations don’t match the discussions in length and I have no idea whether I am given a summary or a commentary.

Ali buys me a small notebook to put down the words I am learning from listening and asking him when I hear a word repeatedly (shagerd = student, nars = nurse; qabela = midwife). It is a little plastic covered booklet with a large feather on top and part of a poem by Thomas Gent (1828): “The beauteous yesterday is fading away light a blushed twilight. Though nothing can bring back the hours of sweet treasured past. I will grieve not but rather find splendor in the memories.” I wonder who decided to print that poem on this booklet in this place. There are no spelling errors in the text and so I conclude it cannot possibly come from China. A local product from a designer with literary aspirations perhaps?

On our way home I am invited to lunch at the boss’ house but when he checks with his womenfolk no one is prepared for such a spontaneous visit by a foreigner. He tells the driver to turn around and takse us to a fast food restaurant, despite my protestations. He orders me a fried chicken leg with fries, to take home for lunch. The rest of the afternoon I catch up on mail, chat with my housemates and start to think through possible designs for tomorrow when one of the director generals with his direct reports (we think) awaits us to deliver on expectations that are far from clear (on all sides).

Towards dinner time Maria Pia opens a bottle of wine; an alcohol-containing present for Steve that goes the way all his other alcoholic presents went (this is the problem when you share a home with transients like us). It is an untold luxury in a place I associate with sobriety. While we sip our wine she treats Hans and me to many stories about the time she was working at Logan airport as Massachusetts first defense against viruses that come in on planes in dead or feverish people, and/or in live or dead animals. She talks about her colleagues from immigration, agriculture and customs and border patrol. They are from very different professional tribes, thrown together in an uneasy alliance with the creation of Homeland Security. I see a book on the horizon.

A toe in the water

More calls, more negotiations, explorations of options, but all separate conversations, one-on-one phone calls, small meetings with key actors missing, not sitting around a table together. This is hardly possible as centrifugal forces pull everyone into parallel or intersecting orbits, never the same. If you’d try to map these orbits it might look like a drawing from an angry child; Separates that do not make a complete wardrobe; stuff not adding up. How anyone can concentrate on doing anything well seems like a miracle. Still, stuff does get done.

I have made a new proposal, just one event, to dip the toes into the water and try this new thing that’s not called a training program. I use the word conversation. It would be actually a series of structured conversations over three days or so with all the key actors of one program together. It would have to be the family planning program because of the funding source but it really doesn’t matter – it could have been any program. And all of the conversations would concentrate on where the rubber hits the road – where the services are delivered in whatever way they are or should be.

I remember from watching a video of Parker Palmer talking about medical education where he insists that the whole patient sits in the middle of the conversation – all the time; something like that. The way to get the – in this case provider-client interaction – in the middle of the conversation I would ask them to spend an entire day either shadowing a community or outreach worker on visits or working side by side with service providers in a health facility (health post, clinic or hospital). It will not be easy to actually organize this, but that is also a matter of finding the right people (it always is), who understand the concept and are excited by the idea.

I wrote a long email to the chief of the Health Services and his HR Director and ended it with a quote from Scharmer’s Theory U book: “On the one hand it is the experience of shaping something: that’s a source of empowerment. On the other hand, it is to see the context in which you and your colleagues work. That changes your view of the larger system. You learn to see the meaning of your work in the context of the whole (region, program). Seeing that larger whole and how you relate to it is empowering. Through your better knowledge about how the system works, how the region (or program works), and by getting to know [all these] people you end up having a different access to making things work – things tend to flow more effortlessly.” (Since I read him on a Kindle I don’t have the page number, one Kindle flaw for people like me who are always looking for quotes.)

Although I am not entirely sure how this will come together I know for certain that this idea will produce the desired outcome: a small group of people who see the potential of such conversations and want more of them, with more people. I dare to stake my reputation on that – if only given the chance. I have done something like this before, nearly 10 years ago in South Africa’s Eastern Cape with the entire top team, led by its energetic chief. Not much came of it I believe because soon after the outing the chief died at the young age of 51. In the midst of paying attention to everything and everyone else he was not paying attention to himself. He died of a heart attack. Since then, when asked “what is the most important thing for leading at the top?’ I always say, “stay alive.’ After all, no matter how good you are as a leader, as a dead leader you are no good at all.

And now, onwards home after a brief catching of breath and buying of cheese in Amsterdam.

Squirreling

Although I didn’t feel so positive as I headed into town to speak with the HR director, road signs tried to cheer me up that good things were afoot. “French begins with you & it is possible” exclaimed a small hand painted sign tacked to a gnarled tree near the city-central cemetery.

A huge bill board from one of the main cell phone companies promised that the world would be one in 2010 and that it (the company) couldn’t wait. The small soccer ball in the corner indicated that this was only true for soccer lovers. The company operates in many countries so the odds are that ‘it’ will win. And then there was the giant national monument promising Freedom and Justice, the national motto, presumably for all; a lofty ideal that still has a way to go.

All over town there are two sets of political signs, one with the candidate who won, and his running mate, sometimes depicted as very dark skinned and on other signs as very light skinned. I wonder whether that is a printing error or intentional to appeal to all shades of Ghanaians; the party that lost also still has its giant signs up saying that their man is the best. May be he was but he did not win.

We had a long and frank conversation about this senior leadership program that I am trying to get started. There appears to be a reluctance to say no to the donors and their particular agendas. I am not hearing the ‘no thank you’ although I have suggested it as an option. Maybe I will hear it today.

Of course there is also the option of looking at the funding, with all its strings attached, as an opportunity to also get something else done or to re-negotiate the strings (possible, I am told by the donor). Once again, it appears to be a conversation that is not happening – instead I witness meetings in which people don’t really say what they mean, or, to paraphrase Martin Buber, don’t mean what they say. No wonder we are all in trouble.

So I have shifted my framing of what we can offer: a series of conversations rather than a training program, in which we can slowly rebuild the feedback loops that have been severed or missing, and hear the stories from the heart rather than the intellect. I think I can do that and today I will find out whether I’ll get that chance. Or I’ll finally hear the no, and I’ll have peace with that too as it means the timing was not right.

It was clear that my unconscious was not done with the events and insights of the day after I went to sleep. One dream put me in a winter landscape, on slippery ground where my guide plunged a long way down into a stream. He could have been killed but he survived. A wild fox that looked suspiciously like Alison’s corky Abby jumped from tree branch to tree branch overhead like a flying squirrel, it colors brilliant against the white winter landscape. I know that in Native American medicine the squirrel tells something about squirreling away nuts for later; busy now with collecting, safe later during the bleak days of winter. I certainly have been busy collecting impressions this week and have stored them (on this blog and in my mind) for later.

I wrote a message in the guestbook for my friend Susan from Alaska who has just been diagnosed with pancreatic cancer. It is odd to be on the guestbook side of Caringbridge, a site so familiar to me as an author during our first 5 months of recovery. I am glad to know how important these messages are and that we are all given the chance this way to follow her in her journey and cheer her and her family on. This journey will take her to Boston repeatedly I suspect and I hope to see her in person at some point. It does put things in perspective.