Scenic Roots
From farmland to mountains beyond mountains
Thank you for your patience waiting for new posts from A Larger Scale as we settle into our time in Lesotho. Moving the family across the world and digging into a new place is all-consuming, and the internet somewhat unreliable, but I will endeavour to take the time to reflect and share.
Also, I’m pleased to be able to offer a discount on copies of A Healthy Future: Lessons from the Frontlines of a Crisis until Dec. 29 using the discount code 0909-20 for 20% off at http://www.ubcpress.ca/a-healthy-future
Scenic Roots
In 1904, my great-grandfather, Emil Meili, left the village of Hedingen, Switzerland for Brazil. He later moved to Saskatchewan where he married and raised his family, farming at Courval a couple of miles from the farm where I was raised (see this article from Maclean’s in the 1930s when he was growing fruit trees in the dust bowl era). When his wife Rose died, Emil moved back to Brazil and spent his final years there.
In the early 1980s, Ueli Suter came from Switzerland to spend a summer with us and learn about farming in Saskatchewan. We had fond memories of his visits and the Lindt & Sprungli chocolates he would send at Christmas after he’d returned home.
On our way to Lesotho, we had a 12 hour layover in Zurich. Abe, Gus and I took the train an hour to Hedingen where we met Ueli, his wife Rahel and their son, Ben. They showed us the house and attached barn that Emil lived in before he left 119 years ago, then took us out to see their land.
The Suter farm is a Swiss classic: Alps snow-capped on the horizon, bells ringing on the cattle’s necks, even a bag of Ricola on the kitchen counter. Ueli was delighted to show us the Saskatchewan license plates on the back of his tractors and other souvenirs of his trip to Canada. It was strangely moving to be looking at pictures from my childhood in someone else’s photo album halfway across the world and to make the connection to the way we are shaped by generations past. On the (very punctual) train back to the airport people kept speaking to me in Schweizer Deutsch (Swiss German) and being surprised I didn’t understand them. First time in my travels I’ve ever been mistaken for a local.
Taking Off Our Sandals
Though I realize this will garner no sympathy from my Canadian readers, it was a bit of a shock to land in Johannesburg the next morning in +35 weather after being up north at -35 a few days earlier. The next morning we flew into Maseru, the Maloti mountain range that gives Lesotho its reputation as the Switzerland of Southern Africa towering in the distance. Maseru is the capital city of the Mountain Kingdom and is where we’ll be staying for the next six months. We are volunteering with Partners in Health (PIH), an international NGO dedicated to delivering “a preferential option for the poor in health care.” This means that, rather than receiving inferior care because of their socio-economic status, PIH believes that people living in poverty deserve special attention because of the disadvantages they have faced throughout their lives, disadvantages that have made them more likely to experience sickness in the first place. In Lesotho, that disadvantage, that inequity, presents as the highest per capita rate of tuberculosis in the word and the second highest rate of HIV.
PIH believes that people living in poverty deserve special attention because of the disadvantages they have faced throughout their lives, disadvantages that have made them more likely to experience sickness in the first place.
The work of PIH in Lesotho started with the Rural Initiative, bringing primary care to some of the most remote areas of the country. It then expanded to include Health Reform – working with the Ministry of Health reorganize care delivery – and the Botšabelo Multi-Drug Resistant TB (MDR-TB) Hospital. We showed up at PIH Lesotho headquarters, suitcases in hand and kids in tow, and were immediately walked through the offices and introduced to everyone working there. Names are long and unique in Lesotho, remembering and pronouncing them well will take time, so we’re grateful that people are happy to be called ‘Mme (mother/ma’am) or Ntate (father/sir).
The next morning we toured Botšabelo, visiting the wards, lab and ICU, with Abe and Gus taking breaks to play soccer in the courtyard. We are keen to learn more about MDR-TB and to get to work at the hospital and in the community. Probably too keen. As doctors, westerners, and our own flawed selves, we want to be working on the wards, curing TB, fluent in the local language and customs all before we’ve even cleared customs. We want to be contributors, partners, not tourists.
When I was first in Brazil in the late 90s, I opened a book of Portuguese lessons for missionaries. On the first page was a quote that has stuck with me since, (translated and paraphrased):
“The first thing you must do when approaching another people, of another culture and other faith, is to remove your sandals. If not, you may forget that you are walking on sacred ground. Or worse yet, you may forget that God was there long before you were.”
While specifically directed at the perils of proselytizing the idea applies equally to health or and other effort to help. The world is riddled with examples of well-intentioned assistance turned into insult and lasting injury. To first do no harm we must first do not much at all. We need to hear from our hosts, to really listen to what it is they’re asking from us, not what we want to give or think they should want to receive.
So we’re listening, and hearing a remarkable story, particularly when it comes to health reform. While less flashy than delivering babies in remote mountain villages or dealing with severe illness from HIV and TB, strengthening health systems can have a far larger impact. Health care management in Lesotho used to be highly centralized, meaning that even minor decisions had to go through multiple rounds of signatures at the Ministry of Health in the capital. The resulting inefficiencies were more than just bureaucratic annoyances, for want of a signature, life-saving medications could be delayed for weeks or an ambulance might not be available to transport a woman in need of an urgent caesarean section.
PIH worked in four pilot districts to set up District Health Management Teams. These groups were given training in leadership and empowered to make decisions locally on transport, supplies, budgeting and charged with supporting the village health care worker program. This led to improvements in service delivery, particularly in maternal health, cancer screening, HIV and tuberculosis.
One of the key features of the program was the decision to pay the village health workers, an extension of the accompaniment model PIH developed in Haiti and uses in all of its sites. Prior to this the health workers were volunteers with little training and sporadic availability. Now they are valued and compensated members of the health team and play key roles in monitoring child health, connecting patients to care and sharing health information. When PIH co-founder Paul Farmer took the Prime Minister of Lesotho to visit one of the sites, the village health workers complained that they were paid and their colleagues in other districts weren’t. This led to national legislation for volunteer health workers and the extension of the entire program, including the district management model, to the entire country.
It’s an impressive story and one that continues to develop with PIH often acting as “Silent Partners in Health,” helping behind the scenes but letting the credit and credibility rest with the Ministry and the developing health system. Over the weeks and months ahead we will continue to learn from PIH’s model and successes and hopefully be able to move from tourists, to guests, to real partners. That progress will be more successful if we’re patient in these early days.
The Long Game
With my brother Jim arriving to visit (and generously help with kid care when we’re at the hospital), we leaned into the tourist role for our first weekend in the country, setting off on a pilgrimage to Roma. Driving standard on the opposite side of a road full of potholes and assertive drivers made for a fun challenge. In Roma, we toured the campus of the National University of Lesotho (whose acronym may amuse our bilingual readers) then watched a soccer game on a grass field in the shadow of another majestic mountain range.
Guided by the triangulation of local directions, google maps, and the description in Will McGrath’s Everything Lost is Found Again, Four Seasons in Lesotho (which is a touching and hilarious account of life and Lesotho, highly recommended), we then headed into the hills behind town in search of dinosaur tracks. We parked by the local church and climbed rocky paths past cattle and sheep, rondavels and sheet metal shacks until we were joined by three young boys. As we approached the top of the hill, an old woman called to us in Sesotho from her front step. She asked for a few Maloti (the local currency) to come through her land and go up to the site.
We climbed over the ridge to see yet another majestic valley (they really are everywhere you turn) and just below us a plateau of orange yellow rock. One of the boys pointed out an indentation in the rocks that was filled with dirt. With imagination one could imagine a foot shape, but it could just as easily be an ordinary hole in a rock. There were a couple more questionable tracks, and then we saw them. Three inch-deep indentations, each about a foot long with three fat toes. 200 million years ago, a great beast had walked this very spot.
In McGrath’s story of visiting the Roma tracks, In the Realm of Vanished Beasts, he captures the feeling of coming into contact with this rare geological coincidence, this solitary clue to a world long past. “The tides of entire species have come in and then washed to sea since these treads were trod, whole civilizations built up from the clay only to melt in the rain. I scan the entire village’s worth of children clambering about the rocks with us. What have any of us learned about durability or its opposite during our transit…We scramble on undaunted, hoping to leave our incomprehensible tracks for whatever beasts come after. We’ll leave them hypothesizing about our glorious unimaginable plumage, guessing all our colours wrong.”
We continued our travels with a visit to Thaba-Bosiu, the night mountain. This is where Moshoeshoe I, the first king of what was then referred to as Basutoland, established his fortress and defended his lands from invaders both African and European. Lesotho is a young land, just a little older than Canada, established during a period called the lifaqane when conflict between different chiefdoms disrupted traditional territories. At the cultural village we learned about the Thaba-Bosiu settlement, the traditional homes of the Basotho people, and the connections to the politics and culture of today. Driving back to Maseru we buzzed for a while about our adventures, then fell silent, taking in all that was new layered on and made up of all that was so very old.
"We need to hear from our hosts, to really listen to what it is they’re asking from us, not what we want to give or think they should want to receive." Thank you for this reminder, Ryan, and thank you for sharing your thoughts on this remarkable opportunity, that you and your family get to be a part of. C.