Bittersweet

Dr. Dorothy, Leah, Rita, me and Pamela

 I just packed up my bag to head back to Juba tomorrow and I feel excited.  I confirmed my flight today so hopefully all goes well and in four flights (Wau-Juba-Entebbe-Addis-Mombasa!!!) I will be in Mombasa by Saturday.  But as I walked around the room today at training I could feel how sad I really am to go.  Today Leah told me, "my sister, you are changing our country".  Pamela told me how much she has learned from me in the past few weeks despite all the trainings she has done alone and curricula she has created, I got teary.  I have been so appreciated here, so welcomed, and I am so honored and grateful to have been a part of it.  
I am also overwhelmed by the change I have seen this week.  Shy, introverted people who could not communicate with me on the first day--and not from the language barrier.  Some crossed their arms and frowned while I spoke about improving the health of South Sudan through family planning and females getting educated.  Sensing their disapproval, I asked if they disagreed and to share, but they did not want to open up to talk or explain their experiences to us, or what felt like was just against me.  By yesterday morning somehow, they were raising their hands, clapping and getting involved in role plays and small groups.  Today, one of those women in the most endearing attempt at English asked me for my email and phone number back home.

Maybe it was all just my new dress.  Pamela and I went shopping in Jeybel market in Juba last week and I picked out a dress that looked like a common style I saw women wear in Juba.  I figured it would be a nice keepsake and something to wear for the training in Wau.  Though women in Wau drape themselves more like those in the north, they really liked my dress.  They said I looked "very smart", which means sharp I think (Pamela says it a lot).  They were sad though that I didn't have a headwrap so one of the women gave me her scarf to borrow to take a picture.  Rita put it on my head, like she wears hers and was about to give me a big hug when that picture was taken.  I think that was a good warmup to the day today!










This morning we discussed emergency contraception and gender-based violence.  Some shared stories of women from the area who have been raped or clients they have taken care of.   Two of the participants are trained in CMR, clinical management of rape and have given out emergency contraception before. 






 The next session, Rita led on her own while Pamela, Leah and I went to meet with Dr. Archanglo at the MOH.  We thanked him for his support for the family planning training and I introduced myself and described my experiences so far in South Sudan with ARC.  He is a very nice, gentle man who is committed to improving the health of Western Bahr el Ghazal.  We not only discussed family planning but also how the war has affected the country and how much development needs to be done.  How can a hospital run when there is no city power or clean running water?  A very humble man, he spoke about his own home not having electricity for the past two weeks because the generator has been down, so he is aware what challenges exist.  He is originally from Wau, but during the war, UNHCR evacuated the area and his family was moved to Fargo, yes Fargo!  They then moved to Rochester, MN where he lived for twelve years and where his family still lives today.  He was very proud talking about his three children who have all graduated from US universities and are doing well.  He says he knew he had to come back to help his country despite being away from his wife and children.

Pamela, Dr. Archanglo and me

Practicing IUD placements

  I want to come back and plan on it as I told Dr. Archanglo today.  I refuse to say goodbye to my new friends tomorrow.  I had breakfast with Rita this morning and we were talking about me leaving and how we would miss each other.  She said, "my daughter, you need to continue to serve these people.  I will pray that you will come back and we will see you again."  We've made small steps these last few weeks but I think its a pretty good foundation to build on.  A piece of my heart will be here waiting

Training participants for the week

Last week in South Sudan

Old sign

Opening ceremony

Mariana and Dr. Ka

Dr. Kanjelo--Director General

Tea Break

GBV Peer Educators who are training in the other room with ARC.  "I'm preventing violence among women" is what their shirts say.

 

 

 

 After a long week of planning, traveling and getting used to my tent, we started training again today.  We have nine Arabic-speaking participants and three participants who can speak English.  There is one medical doctor and the remainder are nurses or nurse midwives.  The training opened with two members of the State Ministry of Health speaking to us on the importance of Family Planning.  Mariana is a health officer from South Sudan who tells me stories of her one daughter (of nine children) who lives in Greece and had her tubes tied after her second child.  "She's so European now, she couldn't even wait to have a girl first!" she says.  Dr. Kanjelo is the director general of the SMOH and seems very committed to supporting family planning. 
I hope to meet with him later this week with Pamela to discuss PAC here in South Sudan (post-abortion care).  I was plagued all weekend by my trip to the hospital feeling useless.  Over one hundred women were sitting in the gyn ward with sepsis and bleeding.  They have prescriptions by their beds so someone in their family can drive searching for antibiotics.  I visited the pharmacy, there are few medications there, no antibiotics and no pharmacies that carry in town.  Other than the general surgeon, who performs sharp curettage, there are no providers for manual vacuum aspiration and not even a speculum around, definitely no syringes.  Pamela, Rita and I can all provide MVAs and yet we couldn't.  So much work to do. . .
One highlight of my trip to the hospital was meeting  Leah, a Kenyan midwife who now lives in South Sudan and is committed to starting Family Planning services at Wau Teaching Hospital and boy she's a spitfire!!  I had a great time meeting her last week and talking with her today since she will be refreshing her knowledge at training this week and brought several of the other participants with her for her crusade.  I am amazed by the strength I see in the people I've met here and the resiliency they have and ability to smile despite all they've been through.  She was telling me how she worked in Darfur providing family planning and how she would get interrupted by the loud speaker announcing a bombing coming in, but she says that's part of her job at times.  She is so committed, I know that she and Silas will get services up and going.  They have a room, supplies from UNFPA are on a truck as I write, and as she says, they must get started right away or that room will be taken from them.  Its a small room so she already has a plan to bring benches outside where women can wait with their crying babies.  She hopes enough people will complain about the noise that they will quickly move them to a bigger space which will suit their needs!  

 While Leah has provided services before, most of the other participants are not aware of family planning methods and have never worked with them before.  Fortunately they are enthusiastic to learn and to provide services.  Today, I started with some reproductive health basics (can you see my beautifully drawn uterus, tubes, and ovaries?!?!).  I went through anatomy, the menstrual cycle and fertilization to start and glad I did, because there were lots of questions.  Rita was a champ translating all day long and cracking jokes so we had a good time.  I did an overview of methods after that and Pamela discussed counseling this afternoon. 
Tomorrow we'll bring samples to show and play with--they are very excited to see what condoms look like! 

Even though this training is basic, I am so grateful to be here and to be able to connect with these providers.  We have had to adjust our goals for the week given the fund of knowledge and resources to train, so hopefully by the end of the week they will be able to provide comprehensive counseling and move on to clinical skills.
I got back to my tent early today since we didn't want to overload them on the first day, so I decided to go for a quick run.  I crossed over the Jur Bridge, went down another long dirt road and after waiting for some cattle to cross, I came upon an after school soccer game.  I couldn't help myself.  I love how universal it is.  I couldn't even ask how to play since they all spoke Arabic, but I walked over to some boys playing on the side of the field juggling and clapped my hands, motioned to my feet and they passed me the ball.  It was awesome!  I played around with them for about 20 minutes and they were hysterical.  They were cracking up at me, and I was laughing at just the whole situation.  I looked back at the road and there were another eight or so people staring, smiling, laughing.  An older man, a couple kids, an older boy who stopped to watch from his bike and a young girl.  I thought maybe she'll get to play some day.  Wish I had my camera. .

First week in Wau

South Sudan Red Cross

 The first week here in Wau has been a peaceful one.  Pamela and I have spent the days both at the hotel and in the ARC office planning for next week and catching up on other things.  I went to the South Sudan Red Cross yesterday to see the room where we will be conducting our FP trainings next week.  Up until the independence, it was the Sudan Red Crescent, but like many things here, that quickly changed with the new republic.

 Silas is one of the bright RH officers who did TOT training with us two weeks ago as well as FP training in Juba last week.  He is responsible for setting up FP services here in Wau once we finish training.  I walked in the office this morning and saw him reading his Managing Contraception, I was pretty psyched!

 Mike, the ARC security officer who came to Wau with us, walked with me around the town yesterday.  You can kind of see in this picture how there are roads besides the roads.  Cars, tuk-tuks (the small 3-wheeled carriages), motorcycles, donkey-pulled water carts, bicycles and pedestrians navigate in and around each other.  The stores and markets are along the dirt road so traffic is a bit chaotic. 
The dress in Wau is much more conservative than Juba, some women cover their heads, the rest are draped almost completely.  English is not as widely spoken except for all the European expats.  I kind of feel like I'm in D.C.  People start off conversation with "who do you work for?" 

Water cart

Tuk-tuk

 Today I met Pamela and one of the midwives Leah at Wau Teaching Hospital.  Its an interesting complex of several small houses each dedicated to another field.  I was a bit lost when I got there and saw a few very friendly faces starting at me from one of the houses.  I walked in and they greeted me with hello and offered me a chair to sit down, so I did.  After barely speaking English to me for a few minutes, I realized I was in the pharmacy.  There weren't many supplies or bottles to give me a clue sooner.  So I thanked them for the seat and moved on to the next house, where I ran into Pamela and Leah.  I eventually met the medical director of the hospital, a general surgeon who just arrived two months ago from Kenya.  He was in his office, a one-room house with a corner separation for exams.  There is an OR but its not able to be used yet.  The hospital is undergoing several renovations to provide more services.  The good news is that there is a room available next to antenatal services which eventually will provide FP services.  Currently there are no FP providers in Wau, no commodities, no supplies, no speculums.  So Silas has a lot of work to do!  He is really committed and enthusiastic though and with Leah and Pamela's help hopefully things will get going in the next few months. 

 So now, to the highlight of my day.  We pulled up to the ARC office from the hospital and there were a couple boys playing soccer (or football rather).  I couldn't help myself, so I kicked off my shoes and told Silas I wanted to play.  He told the three boys something in Arabic, good enough to get them to pass me the ball.  We played around for fifteen minutes or so and I had a great time.  Its like word spread and eventually there were ten kids watching and each car that passed stared with big smiles.  My feet got pretty dirty but considering most people here walk around without shoes, I figured it couldn't be so bad.

 The rest of these shots are some I took driving towards the hospital.  There's a beautiful cathedral you can see the roof of along the main road in Wau.  And I couldn't help taking a shot of the goat hanging out in the shade of the roundabout.  I must say, its sooo hot here.  There's no AC in the office or my tent so I just have a kind of foggy feeling all day long from probably not sleeping so well and then being in the heat during the day.  Because there is no city power, the ARC office runs on a generator and for it to keep working, they have to shut it off several times a day, which means no fans during that time.  Today it was pretty dreadful. 
Luckily there is AC in the room we're using next week for training.  And this time next Friday I will be heading towards vacation and in two weeks I will be sitting in Amsterdam awaiting my flight home to JFK.  I'm looking forward to that, especially the mani/pedi I'll get during my layover.  My poor feet have withstood a lot these last few weeks--they deserve it!!

ARC field office

Wau Cathedral with brick walls seen throughout the city

Typical roundabout in Wau (with a goat)

Moving to Wau

Last morning in Juba with Sadam

Wau, South Sudan

Home for the next week, Tent #4

Yesterday I flew to Wau from Juba on a WFP (World Food Programme) flight.  Its a UN organization that cares for UN workers, NGOs on small flights throughout S Sudan.  The highlight of my flight was meeting a Peruvian woman sitting next to me and getting to speak some Spanish! 
Pamela, Rita and I are staying at the Wau River Lodge which is really nice.  We each have our own nicely equipped tent with bathroom, electricity and a comfortable real mattress (I've been sleeping on a foam pad in Juba).

The people here are very friendly, the atmosphere is a lot more calm and peaceful than Juba.  I already met some ex-pat friends at the hotel as well as some South Sudan friends.  Connie, the director here in Wau, took me to dinner last night at another hotel, the Amarulo Lodge, which was really nice.  I saw a wild African cat which was amazing, unfortunately couldn't get a picture.  It had large rounded ears, was the size of my dog and had black spots covering its yellow fur. . . incredible.  Connie says there will be a barbecue at that hotel this weekend and there's a party somewhere tomorrow night with one of the NGOs, so looks like Wau will be more social than Juba.  Driving home from dinner was interesting since there is no city power so complete darkness other than some car lights.  Getting back to my room was nice without the loud noise of a generator, motorcycles. . . just some light rain on the tarp above my tent.  I was a little nervous for the change, but now I'm very happy to be here.

 The only downside I see so far is the cost of living.  The prices in Wau are double prices in Juba.  I was getting lunch for $3 USD in Juba, dinner for $7 USD and last night my dinner was $18 USD!!!  Amazing how people survive here.  Its much more rustic here than Juba, hardly any of the roads are paved, like I said no city power but no one seems to mind.  People seem less stressed here, my kind of place. 

This morning I checked out the room where Pamela, Rita and I will be doing training next week.  Rita is a nurse midwife from Malakal, S Sudan who is with us to help train and most importantly translate our English into Arabic.  The rest of today I will be in the ARC office working on my systematic review for the CDC and hopefully finish a draft!!  Tomorrow, Silas, one of the RH officers and I will go to Wau teaching hospital to see if we can head over sometime next week to do FP counseling on some patients in the antenatal clinic.  There are no FP services yet set up here so we will not get to do any insertions of IUDs or implants like we did last week.  I can't believe I only have a week left, its gone by sooo quickly!!!

Self-Reliance

Can't help but share. . .
My brother-in-law Scott gave me Self-Reliance by Emerson for my birthday which I brought with me.  Those who know me well, know I love quotes and Emerson is my favorite.  For those who were nervous for me to come here, I wasn't too scared because I knew this opportunity was a gift that came along at the perfect time for me, I saw it as my will aligning with God's.   I just read this:
"God screens us evermore from premature ideas.  Our eyes are holden that we cannot see things that stare us in the face, until the hour arrives when the mind is ripened; then we behold them, and the time when we saw them not is like a dream." 
I just want to say how grateful I am to all of you that have supported me. . . This trip has given me so much already, time and space to let my mind open to ideas and feelings that at other times I would have shut out.  Its been an amazing gift

Last day in Juba

My room in ARC guesthouse

Common room

Kitchen

Courtyard

I'm working in the office today on one of my papers for the CDC and in certain ways it could be my office at home.  Got my laptop, my music, my instant coffee, my GEMMA shirt on, but I'm in Africa.  I hear the loud generator outside, the motorcycles and the rain sounds different hitting the soft dirt and the steel roof.  The air smells different.  And my laptop kind of electrocutes me every hour as I type while its plugged in, another nice reminder!  Its my last day in Juba and I'm sad to go.  I've gotten comfortable here with the people, the places around me.  I took pictures of the guesthouse and of the drive from the guesthouse to the ARC office I took this morning.  There was another storm last night so the roads were a bit messy.  Pamela and I will have our last dinner at UN Ocha tonight and then pack up for Wau.  Its pronounced "wow", so can't be that bad, right. . . 

Thomping neighborhood, Juba Town

Wau will be interesting.  The training there will again be a week of comprehensive family planning training but providers are Khartoum-trained and Arabic speaking.  Khartoum, Sudan is not as progressive as South Sudan, so I'm expecting a greater challenge to dispel myths of contraceptive use and a less enthusiastic audience.  We will see!!  Have to continue to just go with the flow. 

 Moving on to Wau tomorrow means I'm getting closer to vacation and going home.  I am starting to feel the distance!  Getting pictures from my sister knowing the family was in Long Island with Rio makes me a bit sad (but I'm soo happy he's having so much fun).  I am so excited to see him in a few weeks, hopefully he'll be willing to leave after lots of fun with the kids, the beach and my parents!

 Speaking of the beach, I booked my flight to Mombasa, Kenya for vacation.  After debating a few scattered places in Europe and Africa, I figured what better place to go after spending a month with Pamela than Kenya!  And I just love Out of Africa, one of my favorite movies, its perfect I go there.  Mombasa Raha-- what its called by those who live there-- means Mombasa is Joy in Swahili.  She says if you see someone hurrying somewhere in Mombasa, they must not be from Mombasa, no one knows how to worry there.  Sounds like a perfect place for vacation.  So, couple days at the beach and 3 days at Tsavo East and Tsavo West hoping to see some lions and cheetahs!!  Its dry season now in Kenya so should be amazing-hopefully will get some good pictures.  Pamela and I have talked about places we've traveled before and she always asks, do they have safari there?  She was pretty disappointed to hear that there is no safari in Brazil, Costa Rica, California or Mexico.  I will miss her when I leave but I have a feeling I will see her again. . .

 Some interesting facts:
10% of South Sudan has public electricity; 10% of the population can read;                     10% of the roads are paved;                           10% of women have a trained birth attendant at delivery


I'm imagining next time I'm here that all of that will have changed. . .

ARC compound

Kololo (the name of the road ARC is on)

One more. . .

I just walked this morning to the ARC office from the guesthouse (where I'm staying now) so I can get some work done, use the internet.   As I walked along the dirt roads I passed many Ugandan and Sudanese men working in their shops and those waiting on their motorcycle taxis.  I forget that I look different but am quickly reminded by the stares as I walk pass.  The attention makes me uncomfortable and somewhat unsafe as I wonder what they think of me being there.  Just as I was passing a large group of men on motorcycles staring I heard, "When I see a white woman, I see the image of God."  Made me smile and laugh a bit

Interesting things this week. . .

 We finished this week with some fun.  We had one implant insertion on Thursday that one of the postnatal (postpartum) nurses did with me and I talked two officers through two IUD insertions on Friday.  So much fun!!  Here, they use the Jadelle and Sinorod which are 2-rod implants so I even got to put one rod in and then he did the other.  We were so grateful to Marie Stopes and the nurse midwife who took care of us there. 

We came back to Hotel Intra-Africa to take the postcourse test and to hand out certificates.  I was soooo proud. . . the pretest average for the test was 57% and the average on Friday was 84%!!!!  They had prayed on Monday for God to open their minds and fill them with knowledge and they were heard.

 After passing out certificates, the class gave Pamela and I gifts. . . a mat for Pamela to do her meditation and traditional Bari cups to hang milk and drink tea for me (I'm holding them in the picture). 

I'm so excited for them to go on and continue learning family planning and to start counseling patients.  One of our participants is a nurse midwife who speaks on Miraya Radio in Juba several times a week.  She beautifully placed one of the IUDs on Friday and was sooo happy, she can't wait to talk about the importance of family planning on the radio and how easy IUD insertions are!!

After a long week of training, Pamela and I celebrated last night by going to dinner at Lula, an Ethiopian restaurant.  We have enjoyed trying different places together and the conversation is always interesting with Pamela.  Whether it is about her family in Kenya, being a midwife in Nairobi at Kenyatta Teaching Hospital (120 deliveries a day!!!!) or just talking about life.  Last night we enjoyed a glass of wine and relaxed while another thunderstorm hit Juba.  Lula is a large hut with pretty wooden tables and open sides so we experienced some gentle spray from the storm while we had dinner.  Lula has nice music playing and also has two flat screens to watch football or rugby.  Last night they showed some of the swimming championships in Shanghai so I asked Pamela if she swam.  She said, "Well I learned to swim with hippos so I don't think I can swim in a pool."  What??  In Kenya her father would place her on a hippo and when the water got deep she would slide off and would learn to swim.  Incredible. . . I also learned at dinner last night that one of our participants comes from Abeyi royalty (one of the Sudanese regions you may have read about--where all the oil is).  Her father is a King there and he has 40 wives!!!!  She is one of around 200 children!!!  Pamela thinks he had some help from friends creating that many children--I think so too.

I hear interesting things here all the time--stories, but also just phrases.  Even though everyone speaks English here, its amazing how different communication can be from the same language.  Today, Pamela and I had lunch at a Sudanese place eating kisra (a type of Sudanese flatbread), ungali (Kenyan cooked dough), vegetables and soup.  It was all delicious and Pamela wanted me to try some more of her vegetable dish.  I told her I was getting full and she told me, "my dear, today is not the day you will grow fat."  I stopped at the Somali market across the street this afternoon to get a soda and saw my new Somali friends there.  I'm wearing a long black cotton dress and the father who works the register told me, "You look very nice today with that dress.  You are white and the dress is black so it makes you look very shiny."  I find my heart smiling today.

Week 2: Family Planning Training

I love my job!

With their new Managing Contraception books

Thank you Dr. Hatcher!!

 Day one of family planning training was long but SOOO enjoyable.  Pamela and I are doing a comprehensive competency-based family planning training in five days to 13 providers (nurses, midwives, medical officers) who work throughout Juba in the teaching hospital and two health centers.  Four participants only speak Arabic so it was an adjustment to slow down lectures to await translations.  Fortunately, the language barrier did not stop questions!!!

Again, our training started on the Nile at the Intra-Africa hotel.  Day one was filled with lectures and discussions as we reviewed all family planning methods available in South Sudan, medical eligibility criteria and common myths to dispel in the community.

I think my two favorite moments of the day were:
1.  When I explained continuous use of combined pills and how women can avoid their periods.  Mama Rose (older women in S Sudan are addressed Mama) said to me, "Please wait, this must be translated right now, this message is too sweet!!"  They started clapping!
2.  Starting and ending the day with a prayer in Arabic.  In a country where God is everywhere, spoken everywhere, all the time, they understand how important contraception is to women and families and how it saves lives.  It was really moving to end the day like that, all understanding the importance of what they will be doing, God's will.

Today, day 2 we focused on IUDs and implants.  The CopperT and Jadelle (a 2-rod implant) are the two devices available here AND THEY'RE FREE (a Juba Choice project, to all my FP friends)!!  We spent the morning at the hotel reviewing the methods, watching insertion videos and discussing aseptic technique. 

 After lunch, we moved our training to Marie Stopes clinic in Juba who is graciously letting us work with their clients this week to become competent in CopperT and Jadelle insertions.  Marie Stopes is a private international clinic focused on RH.  They see 8-10 clients a day and according to their director, the IUD and implant are the most popular methods women are using!!!!  She says that women just can't be bothered with taking a pill everyday.

 This afternoon I trained half the group in IUD insertion technique with hand models and how to "tent" the skin with the implant model. 

Madam Zoe

 Meanwhile, Pamela taught the other half of the group how to perform bimanual exams and place a speculum to visualize the cervix using the lovely Madam Zoe model. 

Powerful messages on t-shirts are very common here!!

One of our providers has tribal markings on both hands which you can see in this picture.  We spent a large amount of time yesterday discussing different tribal customs and how they affect family planning and reproductive health.  The most common tribes in South Sudan are those of the president Salva Kiir (Dinka) and the vice-president (Nuer), but there are over 60 indigenous tribes in the whole country!  Some examples providers gave us:  Some tribes practice polygamy and those generally do not support sexual activity for two years after childbirth (the husband will "visit with other wives").  Others believe sex immediately after childbirth brings good health to the new baby.  Most people in South Sudan believe that the husband should choose the contraceptive method.  Luckily the trainers from last week and the providers we are training this week believe in empowering the female patients and encouraging partner support for contraceptive acceptability and continuation. 

We have a lot of work to do this week but hopefully we'll see many clients this week.  I'm thrilled to see them sooo excited to learn about family planning and train for the important role of patient advocate and family planning provider (I'm slightly biased!!!)

Will keep you updated!!!  Tara xoxo