final reflection

Our team is dispersing: most of us are returning to Canada but Dave will stay on with Emma for a few weeks in Addis Ababa before going back to Rwanda to help with the foundations simulation curriculum.

Although I am tired after the long flight from Addis Ababa (as I wait for the final flight to Halifax), I can't help reflect that our last month has been enormously productive, energetic and rewarding. We've had great teaching moments, watched learners blossom, seen trainee facilitators become confident teachers, contributed to sustainable simulation-based teaching in Rwanda and Ethiopia and had fun doing so. Our team has shared many laughs and lighthearted moments as well as serious discussions. We resolved challenges creatively and with care.

I am grateful to all the learners and colleagues in Rwanda and Ethiopia who have been so generous. Thank you to the members of the Jan 2019 team (Dave, Stephen, Chris, Jon, Mary, Julian and Emma). Although I will miss you, I hope our paths will continue to cross as the caring anesthesia network around the world grows richer and richer.

with love,

Patty

VAST Course Ethiopia participants and facilitators

strong women

Many of the leaders in the anesthesia department are strong, talented women. How great! The head of department and the head of the Ethiopian Society of Anesthesiologists are both female. Three of these skilled women are helping to facilitate the VAST Course.  Watching them engage with participants and pull out the best performance, is inspiring. Day two of VAST is scenario heavy with 7 challenging OB anesthesia scenarios. We are tired but smiling.

Julian took us to an Italian restaurant for dinner last night - happy, happy, happy
(Laurence, Patty, Dave, Stephen, Chris, Emma, Julian)

Simulated scenario

Team debriefing

Laurence is training Haben; be proud Michelle!

A VAST success

Day one of the VAST Course in Addis. The participants are on time, the space is bright and cheery, the food is more or less on time, the day is bright and sunny. My concerns about people being too quiet during the first session were quickly put to rest - by mid-day people were jumping in with comments and insights and we had to curtail discussion to keep on time. We have a mixed group of anesthesia residents, NPAs, nurses and surgeons. The four facilitators we trained on Monday and Tuesday have exceeded expectations by a huge margin. They are now running and debriefing scenarios with some prompting from our team. It is a huge luxury to have a big team (to say nothing of the talent!). Dave is now a VAST Course pro. An additional bonus is the the level of English is strong and where needed our local facilitators quickly translate into Amharic. Other great moments: Laurence, the sim coordinator from Rwanda, coaching Haben, the anesthesia admin assist. My heart melted to see them sharing a chair and chatting away.  I truly hope this is the beginning of a journey of simulation in Ethiopia. 

Mahder, the head of anesthesia proudly looks at the growing resident pool

Dave and Fetiya teaching on non-technical skills

On to Ethiopia

Our final night in Kigali, we were invited to the home of Francoise, anesthesia program director and a good friend. It was a warm gathering with family and friends.  Francoise gave us a lesson in the African method for carrying a child. Chris and I both made the effort but clearly Francoise is the only one of us who looks perfectly at home with a baby on her back.

Francoise wrapping her son on Chris

On me

Happy African mother and baby

The journey to Ethiopia had a prolonged detour in Bujumbura, Burundi, long delays in the visa line, and what felt like an interminable wait for the shuttle to the hotel. We rolled in around midnight last night, tired and punchy. 

First impressions of Addis - fewer trees, busy, fast paced, lots of concrete, tall buildings, enormous hospital complex, people wearing traditional clothing. We jumped right into a VAST facilitator course today with 3 staff anesthesiologists and a senior resident. Our team expanded to include Emma, an Ottawa resident, and Julian, the CASIEF-Ethiopia lead. Our Ethiopian hosts had arranged a bright airy teaching space and assembled the course materials. We quickly began rolling out the scenarios and were delighted at how well the group picked up the key ideas.

VAST kit

Demo scenario with Emma as simulated patient

Scenario role play

Debriefing

We finished the evening with a traditional Ethiopian meal - communal meal on injera eaten with fingers. We have one more day of facilitator training tomorrow before welcoming 14 participants to the VAST Course on Wednesday. 

Nyamirambo

I brought the team to Nyamirambo last night to walk down memory lane. We took Christophe and headed to the Green Corner for delicious fish (tilapia from Lake Victoria) that is eaten using one's fingers.

This came with Rwandan french fries, so possibly the best fish and chips ever. We wandered down the main street of Nyamirambo – full of people, shops, bars, music and joie de vivre. It had not reached full 2:00 AM fortissimo levels of noise yet, being too early. We stopped at the door of the Guma Guma bar to check that the chairs were all lined up in front of the TV (like church) for the next Premier League game. Indeed, life is unchanged in Nyamirambo. The old apartment building was dark and rather ghost like. Enough of that, we returned to the new apartment and chatted late into the night exploring Stephen's vast knowledge of esoterica.

We are at another transition point. Tomorrow we fly to Addis Abba, Ethiopia to run a VAST Course. CASIEF has a new program in Ethiopia and we look forward to learning more. Chris is the only one of us who has been to Addis before (outside of airport transfers).

As our time in Rwanda comes to a close, I reflect on the visit. It has been productive in so many ways. There is a hunger for our continued involvement, yet at the same time there is a sense of enormous progress. The anesthesia program is well launched and able to function without us. Many people around the country have received extra training and plans are underway to embed the VAST Course as a frequent offering for continuous professional development. 

On a more personal note, I reflect on time. Life is always too short but it is possible to have a rich life where time is enjoyable, meaningful and memorable. That is the gift that Rwanda has given me. Even though we have only been here a few weeks, it seems ages ago that Chris and I were wandering around for our first lunch, we cycled the dirt roads in the northern province, our first Jeopardy game with the residents, watching the fishing boats on Lake Kivu. All marvellous, all rich experiences. 

My future involvement in Rwanda is an open question. I will no longer come as a CASIEF volunteer (too old and no longer practicing anesthesia at home) but I suspect I will return in some other capacity, perhaps a family visit with all the people who consider me their Canadian mum.

Excuse me. Come again?

From Jon

 

Being a geographically small country, Rwanda is linguistically (and culturally) very homogeneous.  Day to day most Rwandans speak Kinyarwanda, but due to Rwanda’s French colonial past, most Rwandans grew up also speaking French.  Elementary school instruction for most of the country’s independent history was in French. However, in 2009 Rwanda intentionally became a member of the commonwealth and the official academic language became English in schools and colleges.  This means that most Rwandans are fluent in Kinyarwanda, and at a somewhat lesser extend English and French.

That being said, many of the difficulties in communication are most complicated than simple linguistic misunderstanding.  Let me give you a few examples.  

While staying at the Gisakura guest house, we decided to plan the rest of the weekend and upcoming week.  I turned on my computer and noticed a Gisakura wifi network.  I walked to the desk to ask for the password.  

Somewhat timidly I ask, “Excuse me, can you tell me the wifi password?”  

The desk clerk replies, “I don’t think the wifi is working very well right now…” looking down at the unplugged wifi router sitting on her desk.  

I, not realizing this – in retrospect very obvious non-verbal que – persist.  “Well, I see the wifi network on my computer.  Can you give me the password to try?”  

The clerk again looks at the very obviously unplugged router with a very long pause and a slightly confused look on her face… then reaches for a piece of paper and writes down the password – I imagine deciding that it is just easier to avoid conflict by quietly leaving with the router for the night rather than to argue with this somewhat slow muzungu.  By the time I realized that the password supplied was not going to solve the problem, I also decide that just using a cellular hotspot was easier than arguing about the wifi.

The following morning, we enter the Nyungwe park office to be greeted by a friendly park ranger. “Good morning.  You are welcome!” he says gesturing to a single chair.  I look at the chair and the other three people with me and decide to stand.  We all shake hands and exchange pleasantries.  Now with all four of us standing near the desk he more emphatically says, “Please, have a seat” again gesturing to the single chair.  I decide he really wants at least one of us to sit down so I sit. Proudly he explains “We have many activities in the park: monkey tracking, hikes, nature walks, the waterfall hike, the canopy trail.”  Given that we came solidly unprepared and really open to any outdoor park related activity, we attempt to clarify are options.  

Chris offers “I hear there are some packages for the trails. Is that true?”  

“Yes, sir. You can enjoy many trails with the package. There is a package for short trails and a package for long trails.”  A long pause clears the fresh mountain air.  

Chris tries “which trails are included in the package.” 

The ranger helpful says “the waterfall trail leaves from here at 9am.”  

“So, the waterfall hike is included?” 

“Sorry, no, sir.  The waterfall hike is an additional fee.”  

“Oh” Long pause while recalculating… “So, can we do the waterfall hike in the morning and then go on some other hikes in the afternoon?”

“Sorry, sorry.  As you can see (gesturing to his watch reading 9am on the dot) you have missed the waterfall hike today”

Being that we had no firm plan, we were undaunted at this point.  “Ok, that’s fine.”

“Thank you, sir.” Smiling

“Can we go monkey tracking?”

“Very good. We have 13 different species of monkeys here in the park!”

I break in at this point.  “Great! How many Colobus monkeys are there?”

The guard looks up and appears to be counting in his head, responding after some time “37.”

“Ok, when can we see the colobus monkeys?”

“Tracking for colobus leaves 8, 10, (thoughtful pause) 1 and 3.”

“Great. Can we go at 10?”

“Yes, sir.  May I please have your passports.”  

We hand them over and begin to chat while he carefully writes down our information.  Then we he is almost done registering us, he says “The ranger tells me the colobus monkeys in the trees now.  They may be somehow difficult to see now.  Maybe it’s better not to go now”

Now admitted becoming disappointed and somewhat comedically frustrated, “Ok, fine. Can we go on a nature hike?”  

“No problem, sir.  They leave from the Uwinka office.  You can register for them there.”

“They can’t use the information you have here”

“No sir”

Now trying forcefully to remain upbeat, “Ok.  Thank you for your help.  Do they accept visa cards at the Uwinka office?”

“Yes, sir. Only visa.”  

Upon arriving at the Uwinka office (13 windy mountain road kilometers away), the ranger there informs us that they only take cash.

 This kind of miscommunication and misunderstanding is endemic in global health work either in or outside of the operating room. It plagues our ability to be effective and the fault does not clearly sit with one person or group of people. It can be at times comical or mildly frustrating, but at worst it can lead to conflict, destruction of long fostered relationships and even medical error resulting in harm.  The most concerning aspect is that Canadian and (even more so) Rwandan culture tends toward being polite, overlooking perceived minor missteps.  This means that miscommunication can go unnoticed until too late.  The answer is likely that miscommunication decreases gradually as we understand each other’s culture, the words we use, our verbal ticks, and we strength our relationships between people.  We can improve things but miscommunication will remain an ever present reality of working cross culturally.

All photos by Jon:

Colobus monkey

leaping monkey

tea and hills in Nyungwe

three amigos in the tea

colourful bird

mountain monkey

tea fields

Nyungwe

tea factory

people moving

When I first came to Rwanda in 2008, there were few private cars. Most roads were dirt, there were few sidewalks, no street lights and pedestrians had to navigate their way over mounds and around pits.  Now much of Kigali is paved with sidewalks and good street lighting. Private car ownership is growing, with a resultant deterioration in air quality.

But Rwanda is always innovating. I read in the local newspaper today of plans to install a cable-car network in Kigali. The study designers argue this will move people efficiently and will reduce greenhouse emissions, noise pollution and collisions. Furthermore, the study recommends transportation corridors for pedestrians and cyclists. Wow! This visionary thinking is what is helping transform a tiny landlocked African country into a significant regional player. Could we please have efficient public transportation and corridors for pedestrians and cyclists in Halifax?

Meanwhile, we make do with other transport options.

muzungu on a moto