diary of an emerging social enterprise

Just to give some idea of how much we are moving around, and the means by which we are doing it, we are launching a little travel report called “On the Road.” You see, we want to get an idea of how local people travel and to understand the challenges of moving long distances by road transport. So Shannon and I take public transport everywhere we travel. While certainly not the most comfortable mode of travel, public buses are undoubtedly the most educational.

Every time we move, we will update a map and a summary count of distance and time. For the details, just look below the map.

Total Distance: 1,444 miles (2,323 kilometers)
Total Transit Time: 62 hours

The light blue color indicates a road we traveled down twice.

• Kigali, Rwanda to Goma, DRC - 80 miles by bus - 4 hours
• Butare, Rwanda to Kigali, Rwanda - 57 miles by bus - 2 hours
• Kigali, Rwanda to Butare, Rwanda - 57 miles by bus - 2 hours
• Kampala, Uganda to Kigali, Rwanda - 275 miles by bus - 9 hours
• Nairobi, Kenya to Kampala, Uganda - 375 miles by bus - 14 hours
• Mombasa, Kenya to Nairobi, Kenya - 300 miles by rail - 14 hours
• Nairobi, Kenya to Mombasa, Kenya - 300 miles by rail - 17 hours

At breakfast the next morning, Lyn and I chatted through some ideas regarding developing an expansion of her cleft palate program and preparing a grant application to The Smile Train to fund it. Lyn wanted me to get a deeper understanding of HEAL Africa’s outreach mechanism and arranged an agenda for the day.

I started out learning about the Safe Motherhood Program. This community-based prevention program very cleverly leverages local competency in order to make motherhood safer. The trick is that the HEAL Africa program embraces all elements of the service chain. Working in 82 health centers in 4 territories, HEAL Africa engages community leaders to gain support to start training – first, the health workers and then the traditional birth attendants (TBAs). Often, these TBAs are left out of planning and action because they are not qualified health workers, but the reality is that many rural women turn to these TBAs as their primary source of obstetric services. Finding a way to work with these TBAs is critical to reaching rural woman, yet paradoxically, it is an element often left out of public health systems planning. This exclusive structure pits health workers against TBAs and results in the two groups working against each other. But by training the TBAs with the health workers and creating inclusive structures, HEAL Africa facilitates a symbiotic relationship and a deeply-reaching referral mechanism.

After training people, HEAL Africa provides health workers with basic equipment including plastic tubs and mattresses and TBAs with kits containing buckets, lanterns and blankets. While these items cost very little, they make a remarkable impact on motivating the health providers (both trained and informal) and improving the safety of childbirth. HEAL Africa has also set up over 130 Solidarity Groups, essentially clustering over 4,000 women of motherhood age into income generating teams. In addition to producing profit that acts as a maternal health insurance fund, these groups also create an empowerment bond that has women looking out for each other amidst the calamity of war. Of all the projects these groups do, I thought making baby clothes was the coolest. In most parts of North Kivu, newborn babies are wrapped with dirty blankets or left uncovered all together. But the Solidarity Groups make baby clothes that HEAL Africa buys and offers free to any baby born at a participating health center. Women who would have had their babies in villages trek well out of their way to get this $1 perk and deliver their children in supervised environments that are safer for mother and baby alike. Now that is social innovation!

That afternoon we hopped in a jeep and headed out to a school partially funded by HEAL Africa. I tagged along on this visit, mostly just to see a bit of the area surrounding Goma. The school was situated a couple miles off the main road and directly adjacent to an enormous UN Refugee camp that had moved there about a year after the school had been built. As we slowly crept down the lava road that ran along the camp, I peered down the endless rows of rounded straw huts wrapped in white plastic tarps that almost looked like a neighborhood of igloos. The displaced people had lived in this “temporary camp” for several years and there was really no end in sight. I saw sad, empty faces, weighted down from the struggle for survival and the absence of hope. I couldn’t help thinking about how awful it would be to grow up in such a desperate environment. These unsettling thoughts stayed with me even after we arrived at the school, which provided quite a contrast in terms of possibility. As I watched the singing children play happily in their school yard, I couldn’t take my eyes off of the white plastic valley of hopelessness in the background.

We stayed at the school a couple hours and then headed back over to Grounds for Hope, the long term fistula care center we visited earlier in the week. In this day, I had already travelled from the excited lightness of the morning’s safe motherhood discussion to the dark heaviness of the refugee camp. I wasn’t talking much as we bounced down the dirt road in the HEAL Africa jeep, but I was thinking as I stared out the window. That’s when I saw him. We turned a corner and there stood a man on the side of the road. His wide eyes were completely focused on our jeep and his dusty hands cradled a Kalashnikov assault rifle. I don’t recall how the rest of the car reacted or if anyone even noticed, but this site took my breath away. Here stood a man in a sleeveless black t-shirt and tattered green shorts – not a soldier, but a farmer - too poor to buy shoes or a shovel, but armed with immediate and deadly force. Time seemed to abandon us as we passed this man, returning only as we turned the corner and escaped his gaze. This sight shook me up and I outwardly wondered why the gunman allowed us to pass. The other passengers told me that because HEAL Africa is a Congolese organization and so well respected in North Kivu, they had never had any incidents when traveling in marked vehicles. I began to understand why every HEAL Africa car had the logo hand painted on the doors and usually flew HEAL Africa flags out the window in addition. Even with the explanation, I still hoped we wouldn’t run into our machine gun-toting friend on the way home.

Luckily, we didn’t see anymore gunmen on the ride home, but instead we had the good fortune of some stunning views of the volcano. The events of the day dominated my thoughts. Seeing exactly how tough the outside environment was in a relatively safe area made HEAL Africa’s work even more impressive to me. I resolved to understand more about how they established such a presence amidst so much instability. Over dinner, I quizzed Lyn about their outreach process and discovered HEAL Africa’s outreach enabler: the Nehemiah Committees. Like other groups doing good work in the chaos of conflict, HEAL Africa is a faith-based organization. To build a network, HEAL Africa approaches community leaders, most of whom are religious leaders of various faiths, and invites them to a workshop to read the Book of Nehemiah, an account of the rebuilding of the wall of Jerusalem. Since its part of the Old Testament, all Abrahamic religions recognize the Book of Nehemiah and are willing to discuss it. This important detail enables HEAL Africa to engage both Muslims and Christians, alike. The reading workshop is intended to create a Kumbe Moment in which the community leaders commit to developing a cross-faith committee that works to protect the rights and interests of the society’s most vulnerable people. Through these committees, HEAL Africa is able to offer services to the most needy people in the most isolated places.

After a volatile day of intense emotions, I fell into bed feeling really good about our trip to the DRC. Though we would be leaving soon, the trip had been an incredible success. We learned volumes about holistic services and creative outreach mechanisms and we were even able to lend a hand with the Smile Train grant application. I fell asleep wondering what was next.

The short night had not only robbed me of slumber but it also nearly made me late. I scrambled to get dressed and missed breakfast in my rush to meet Dr. Jo Lusi, who I found waiting patiently in his jeep with the passenger door open. As I hopped into the jeep, Jo put a tape into the car stereo and immediately started singing along with music. In between his accompanying vocals, Jo explained the reasons why this Congolese singer was a legend and exactly why her voice was so magical. I remember the reasons, but have forgotten her name…

Lulled into an absolute state of relaxation by the melodic commute, I was not prepared to chase Jo as he burst from the almost-stopped car. But lucky for me, he spotted some clubfoot patients before Jo could get too far from me. Having spent considerable time the night before discussing this devastating and correctable condition, Jo was excited to show me and I was thrilled to learn more. The kids absolutely love Jo and as he knelt down to show me the cast of one boy, I noticed several others waiting their turn for even a small amount of Jo’s attention. He made an example of each of the children, showing me the nuances of exactly the same cast multiple times. Jo’s passion was evident and it was less for the cause than for the kids whose lives he was transforming. After he had attended to each of the boys in the yard, Jo rushed me onto a quickly-paced jaunt through a maze of wards.

As we bounded through the dizzying and emotional tour, I found myself overwhelmed by the sheer number and magnitude of sad stories in the ward. Everywhere we turned there were crowded wards full of kids waiting for surgery, all living with different debilitating and very visible ailments. There were several babies with clubfoot, and a few with hydrocephalus, a condition where the skull fills up with water and expands to an incredibly large size. There were also several kids with cleft palate, a condition that those of you who were part of Summit for Smiles know is very close to my heart. Other wards had direct victims of violence, from burns to gunshot wounds, but the saddest and most haunting patients were the survivors of sexual violence. Their wounds were much more than physical.

Every square foot of space in the hospital had a body awaiting medical attention. When I commented on the numbers of patients to Jo, he smiled and said, “You know, this is the second floor, right?” As my face contorted while I considered the logic for building a basement ward, Jo started laughing. It was only then I realized that he was referring to the hospital that stood on these same grounds before the volcanic eruption destroyed everything in 2002. As tough as things were here now, I imagined how awful it must have been for the citizens of this region when HEAL Africa’s buildings had been consumed by the lava only 6 years earlier.

It was when we were nearly running to get to another part of the complex that Jo abruptly stopped and turned to look me right in the eye. “Seth, I love your idea and I think you can really help, but if you really want to make a difference, you need a Kumbe Moment.” Hmmm, I could hardly disagree. So far, Jo had been nothing but insightful. I wondered what a “Kumbe Moment” was and where I could get one. Just as I drew the breath to ask, the smiling Jo launched into his colourful explanation. “A Kumbe Moment is a discovery – it’s when you realize something you didn’t know before and you say, ‘ahhhh, Kumbe! – I get it now.’” This is where I expected Jo to reveal the great flaw in the OperationOF strategy – the Achilles heal that would keep our burgeoning social movement from greatness. I began to consider the volumes of things I didn’t know, scouring the seemingly infinite list for the one detail that would sink us. Jo’s laugh brought me out of my trance, “Seth, the Kumbe Moment you need is with African doctors.” Completely enthralled, I nodded and breathlessly paused for the second half of the insight. “If you want African doctors to really work on something, you have to show them why it is worth their passion and focus. You need to inspire a Kumbe Moment where they deeply understand and connect to the cause. Otherwise they will simply take your money, say all the right things, and dance your dance until you leave.”

Completely shocked from the unrestricted candor and incredible insight, I was not only speechless, but I also must have had quite the look on my face. Jo looked at me with concern, patted me on the shoulder in an it’s-gonna-be-alright kind of way and said, “Check out Healing Arts and let’s catch up at dinner.” And with that Dr. Jo Lusi quickly floated away. I took a moment to catch my breath and absorb what Jo said and then wandered over to Healing Arts.

To say HEAL Africa has a holistic approach to healing is a bit of an understatement. Instead of simply merging the medical and psychological aspects of treatment HEAL Africa also includes the economic and emotional well-being of patients and their families as part of their strategy. An important component of this effort is Healing Arts, the textile business that allows patients to produce and sell anything from wristbands to dresses. A room full of classic-looking Singer sewing machines had a woman at every terminal, each crafting some ware with the beautiful and colorful fabrics native to this land. Even in front of the building, there were women hand-sewing simple fabric bracelets as their children played in the black gravel of open space. Melody was ever-present with these women and from a distance they sang beautifully simple songs as they stitched fabric in the sun. Only when they noticed me approaching did they grow quiet and shy. Determined to capture some of their lovely songs, I set up a mic and walked away. Only after several minutes of my absence did they resume their harmony. Here is a little clip of what I recorded, though it hardly does the original version justice.

Shannon and Jackie (a doctor we met in Rwanda who joined us in the DRC) were measured for some custom fitted clothes and when they were done, we all headed over to the little hospital school room. As mentioned, HEAL Africa goes to great lengths to fully engage as many people as possible while they are in Goma. This includes offering a young patients an opportunity for some lessons taught by a psychologist-in-training named Charles. Shannon mentioned a bit about this visit in her blog, so I will only say that we have posted a short slideshow in the pics section of the blog that includes some of the songs they sang for us.

When we finally returned to the paradise of Maji Matilivu (the guest house), we found Lyn Lusi clipping roses in her beautiful garden. After a short tour through the garden, I found a quiet place to ponder. I could not stop thinking about all I had seen during the day. I thought about all those patients waiting for a chance to heal and how limited general surgical capacity affected each of them by delaying their turn for treatment. I thought about how adding specific capacity for fistula could potentially benefit all patients, but wondered how I could help an organization already doing over 200 fistula surgeries per year and doing them well. Even though we had come here to learn, I really wanted to help, but I just could not figure out how.

I had my “Kumbe Moment” at dinner. Lyn was describing some of the difficulties of serving such a broad set of constituents over such a large and tumultuous area. She discussed how certain conditions get left out because of limited skill set or funding. In this discussion, she mentioned cleft palates as one such condition. I immediately lit up and nearly screamed, “ahhh Kumbe!” After the initial scare I gave the table, I went on to explain my epiphany. If we could get funding for cleft treatment, it would allow HEAL Africa to expand their organization and eventually serve more people, including women with fistula. I suggested we work on an aggressive growth strategy and prepare a grant application for funding from The Smile Train, who I met with last May in New York. Of course, this spurred an excited conversation that lasted far too late and kept my heart beating far too vigorously.

I climbed into bed through a cloud of thoughts, considering precisely how treating children with cleft palates could indirectly benefit women with fistula and knowing this would be another long night.

I’m not sure if it was the flashing Travel Advisory by the State Department or the stories of people being detained at the border, or maybe everything I had read about the Democratic Republic of the Congo (DRC) in the Spring semester as I had studied sexual violence in the Eastern region, but the air seemed to have a overt sense of explosion. The DRC has been embroiled in a horrible regional and civil war for the past decade that has cost the greatest number of lives since World War II. Currently a ‘ceasefire’ remains in place but as we quickly learned, words and signatures on an agreement are trivial in an environment where human life has little value.

Signs of the war were palpable as we toured the hospital grounds observing victims of gun shot wounds, burns, and rape. The fighting continues and the most horrific consequences fall on women. Rape has systematically been used as a weapon of war in the Eastern Congo in an effort to demoralize, deject and destroy communities. The violence has not subsided as over 2,000 women reported rape in North Kivu in the month of June alone (although the true figure is likely much higher as cultural stigma is assigned to the victims). Sexual violence continues on an unimaginable scale and women who survive such harrowing experiences can derive a traumatic fistula—a tear in the vagina from violent rape. Violent injuries like traumatic fistula are generally less common than obstetric fistula, which results from lack of access to maternal healthcare systems. In regions of war and instability, increased violence coincides with a complete break down of already dysfunctional systems and absolute catastrophe ensues.

My months of reading and research materialized as we walked through the doors of the female ward. An elderly woman shuffled around her bed, using the edge to support her frail body. When our eyes met, she stopped and I watched this poor woman hunched uncomfortably over her bed, every line in her deep brown skin and the faint light in her eyes conveyed a lifetime of hardship and tragedy. When Dr. Jo told us this eighty-four year-old woman had endured a violent rape only a few weeks earlier, my heart sank. I wondered how a human being could purposefully inflict so much pain and suffering on the life of another. This woman was waiting for a corrective surgery to repair the traumatic fistula that violent encounter left her. Despite appreciating the service HEAL Africa offered this woman, I felt heart broken that this grandmother in the twilight of her life should ever need such an intervention.

Some cases of fistula are not easily corrected and require multiple attempts at surgery. Around 10% can never be healed because so much tissue has been lost. HEAL Africa established a small commune of women with complicated or irreparable fistulas who live and work together several miles outside of Goma. The commune collectively produces soap and textiles to sell as well as raise rabbits for food and manages a large garden for vegetables. Some women have been there for weeks and others for years but they have all bonded like sisters and mothers, taking care of each other, giggling and gossiping. The community is called “Grounds for Hope” and the name lives up to the mood in this compound. Most of them are smiling and affectionate, which is encouraging to see when you consider the emotional trauma that lurks just below the surface.

While we were there a beautiful young woman was visiting Grounds for Hope. This young woman, lets call her “Rebecca,” had lived at the commune while she healed from her complicated fistula and wanted to come see her friends during her school break. Her story is disturbing. At 14, a rebel militia man courted her and when her family refused to give her hand in marriage, the militia responded by setting her home ablaze. She was not there, but several members of her family were trapped inside and burned. Rebecca continued to escape abduction until the rebels finally caught her and made this adolescent their slave in every sense of the word. By 17 she had survived rape, pregnancy, and a prolonged labor in the bush that left her with a fistula. Leaking urine, Rebecca had little worth to the militia and she escaped before they murdered her. She eventually found her remaining family and Heal Africa and returned to school – the only subject that really made her smile.

We had a chance to visit a school HEAL Africa created to accommodate young patients or the children of patients as they waited to recover. When we first walked in the small classroom, the scene in the class could have been a school house anywhere. The kids, obviously overjoyed to have visitors, sang welcoming songs and were eager to see where we came from on the map. After this very warm welcome, the teacher wanted to show us the affects war has on the children asking basic questions such as ‘what do you want to be when you grow up?’ The traumatic scars of the war emerged in their answers. One gregarious boy stood up and replied ‘NOT a soldier!’ as he recounted the night soldiers came into his home, beating his mother and stealing all of their belongings. In this brief encounter, we heard these children calmly recount unimaginable tragedies - for a child should see their father abducted or their sister raped and to recount it so unemotionally…its an unsettling experience.

Press reports and articles in magazines cannot fully capture the absolute chaos of the Congo. But in an environment where little provides hope, HEAL Africa is a wellspring sanctuary offering some note of redemption in such a destructive place.

Click here to see a short video slideshow from our recent trip to Rwanda.

Safety first. Every decision on this trip has started with ensuring that we have a safe and secure environment. This is actually a big challenge considering that fistula is prominent in the most desperate places and that getting to such places usually means piling into overcrowded rust boxes that zip around corners and over potholes at breathtaking rates.

After hearing Lyn Lusi describe HEAL Africa’s innovative approach last April in Accra, I really wanted follow up my enlightening encounter with a visit to the Democratic Republic of the Congo. But because Shannon spent last semester researching this region, specifically atrocities committed against women there, I had reservations about crossing into this wild and war-torn region. To mitigate what I considered our greatest exposure, I set two security conditions: (i) someone walks us through the border and (ii) we stay within the HEAL Africa compound. We didn’t immediately hear back from the HEAL Africa team and as we waited, both Shannon and I started to question whether or not we should follow through with the visit. But a chance meeting with a Belgian midwife who had just returned from a remote part of North Kivu combined with the affirmative response we heard from HEAL team finally pushed us over the edge.

I wasn’t actually sure how any of us were going to fit into the battered, red matatu (read minivan), but the three men sitting in the back row of this crowded Nissan seemed to manufacture a place for me to sit. Despite sardine seating, the ride to Congo was magnificent. The growing height and scale of the hills was only countered by the severe depth and drop of the valleys. The road seemed to float around sharp turns, but the turning forced a collective sway of the four grown men pressed shoulder to shoulder in the back row. On every hairpin twist, a view down the steep slopes or across the valley revealed endless swarms of banana trees attacking the hills like angry, green-winged dragon flies. Gasping from the ride, my breathing was further challenged by the shear beauty of Lake Kivu, which abruptly presented itself just before the border.

After a short walk through a no-mans-land that doubled as a vegetable garden and the near-theft of our yellow fever cards by an alleged official, we were bouncing through the volcanic ruins of Goma en route to HEAL Africa. Goma was destroyed in 2002 by a volcanic eruption and the shattered state of the Congo meant that very little was rebuilt. This left a dusty ramshackle of lean-tos partially rebuilt on the flowery curves of hardened lava. The molten rock destroyed many roads as well, but over time, the unceasing flow of traffic pulverized the jagged black remnants into a fine dust that, when mixed with car exhaust, formed a sinister cloud that ominously hung everywhere cars dared to venture. The chaotic jumble of movement seemed to expand and contract at will, encompassing every type of transport as well as people carrying everything you could imagine. The direction of this mass movement had no order whatsoever and the only factor potentially limiting the blob was the mass of buildings at its margin.

When we pulled into the grounds of Maji Matulivu (HEAL’s resident compound), I was amazed at the stunning contrast to the streets outside the gates. Lyn and her husband Dr. Jo Lusi built an oasis on Lake Kivu and the place was teeming with young people working on a wide variety of projects or doing nursing rotations on a semester break. With a clear energy in the air and dusk approaching, we sat down at the lakeside for a group dinner. Eager to discuss the fine points of how HEAL Africa had been so successful creating service structures in the complete absence of stability, I launched into a series of questions. As he humored my queries, Jo (who is an orthopedic surgeon) told me about his passion: club foot. I had never heard of this highly correctable congenital birth defect that makes feet grow in unnatural directions, but Jo showed me some incredible pictures of what his intervention had produced and I could not believe my eyes. Jo went on to describe the process of correction and some of the challenges he faced helping children with this devastating disorder. Our passionate discussion gained so much momentum that time evaporated and we were eventually the only people at the table. Given the late hour and our 6am start, we agreed to continue the dialog the following day

But trying to sleep was no use to me. Like a kid at Christmas, I anxiously waited for slumber to pull me into its grasps, but the promise of an electric week full of inspiring surprises filled me with anticipation and kept me just beyond the nocturnal world for what seemed like an eternity.

I spent my 24th birthday at a hospital in Butare, Rwanda, meeting sad yet hopeful women awaiting fistula surgery in one of only three places in the entire country where this is possible. After months of reading patient histories, personal tragic stories, UNFPA reports, maternal morbidity statistics and health delivery system studies—anything tangentially related to O.F—I was actually standing in the maternity ward looking into the promising and serene eyes of a woman who had been leaking urine for more than two years. She sat timidly on the edge of a worn mattress, holding a beautiful baby boy, born in the bush despite her fistula. It was only as I touched his tiny head that she smiled radiantly; a smile that conveyed her dignity as both a woman and a mother.

When we met Dr. Kakoma, the head of obstetrics and gynecology, we were immediately impressed by his passion and knowledge. The Congolese surgeon actually shocked us when he said that only one urologist serves the entire population of Rwanda (almost 9 million people). But as Seth described our organizational plan to change the fistula world, Dr. Kakoma’s face lit up with excitement and he began talking rapidly about all the possibilities a few more resources would enable here in Butare. The National Teaching Hospital currently maxes out at around 50 surgeries per year, a drastically low number considering that 10 rural districts refer into this relative center of excellence. We believe our operational expertise and some investment could improve this amount up to five fold. Such dramatic change could be accomplished through training staff and adding infrastructure necessities such as more instrument kits, an expanded ward and potentially a fistula operating theatre. Dr. Kakoma connected us with a couple young surgeons who gave us a thorough tour of the facilities.

Despite their commitment and skill to conduct operations, surgeons in Butare are challenged daily by limited hospital facilities as the maternity ward is grossly under-funded. The uneven floors, broken beds and cracked walls are jarring to the senses but at the same time the miracles that are being achieved with such little material resource are incredible. The scrubbed up surgeons expressed the challenges of working with only one instrument kit, insufficient catheters, too few beds and an inadequate supply of medicine. Despite the tough conditions, these dedicated few have committed their lives to serving the mothers of this country and only made modest requests for instruments and training that would assist them in doing their job better. Their hearts were clearly with the women, but in a country trying to rebuild after such recent devastation by a horrific genocide, resources and government healthcare assistance are not exactly in abundance. As we left Butare, it was clear to us that this was one place that could surely benefit from some assistance.

We boarded the overnight train in Mombasa knowing about the possibility of massive delay (and derailment), but hopeful that the law of averages was on our side. After a fitful night of interrupted sleep, I woke confident of our on-time arrival. The train is a great way to travel for a view of the country and certainly beats simply popping in an out of airports. Though great, the views can last a bit long at times, as the African train slows and sometimes stops briefly in smallish towns where the locals, especially the children, take an interest in the passengers. On more than one occasion we noticed the local kids racing the massive locomotive as it began to build speed on its way out of town. These barefoot children maintained pretty impressive speeds on the rail yard gravel.

As excited as we were to get into the field and start reviewing potential pilot sites, we still had a pretty reasonable backlog of information gathering and analytical modelling to complete in Nairobi. A friend of mine got us into the “members only” Nairobi Club, a delightful colonial leftover that provided us with a warm workplace much more like the fraternity house of my academic years than the office cubicles that had stolen the summers between them. Despite the workload and a super office, our time in Nairobi had to be very brief. Our solidifying agenda revealed Uganda as the country we would spend the most time visiting, and we still planned to visit a Ugandan surgeon in Rwanda and possibly an innovative Congolese doctor in Goma. We looked at flying to Kigali, but interregional African flights are terribly expensive and not particularly air worthy. The cheapest alternative is to spend the night on a bus, but bad roads and limited visibility had us nix that idea for safety reasons. This meant finding a network of connecting day buses that let us inch our way around Lake Victoria and into Rwanda.

While Shannon was busy coordinating our continental bus transit, I met with Dr. Tom Raassen, a native of Holland who has spent the last 30 years helping the women of East Africa. Besides treating thousands of fistula sufferers himself, Tom has also trained a sizable population of surgeons throughout the region. When I met Tom in Accra in April, he agreed to meet with me in Kenya and, despite a very busy schedule, he kept to his promise and sat down with me at the Nairobi Club. This meeting turned out to be one of the most productive of the trip as Tom shared his expertise in capacity building and helped me better understand fistula center infrastructure requirements and how to rapidly facilitate human resource development (especially in terms of surgeon training).

Shannon managed to get us the last two seats on a 14 hour bus from Nairobi to Kampala that left the next morning. With an afternoon to spare, we went to visit my friend Becky Chinchen, an American who runs a social business called Amani ya Juu. Amani was borne from Becky’s experience in Liberia. Having fled the country during the devastating civil war, Becky set up a very small operation in Kenya that sought to create peace and reconciliation through textiles. With a huge heart, a sharp mind, and a keen eye for quality, Becky built her little venture into an export driven women’s empowerment movement operating in several countries and continents. The grounds of Amani are the most inviting I have experienced in Africa and Becky says she “just wanted a peaceful place for the ladies to work.” Amani hires refugee women to produce high quality fashion and accessories that are not only saleable in western markets, but are actually on the high end of the quality spectrum. Amani pays these women 3 times the minimum wage and even encourages them to start their own businesses employing other women to produce products for sale to Amani. Not only was everyone we saw glowing with happiness, but they also leapt up from their sewing machines when we entered the production room and proceeded to surround us with a joyful welcome song.

The comfort of our afternoon with Amani contrasted greatly with the next morning’s transit to Uganda. Stuffed into the last seats of a roller coaster bus that bounced hundreds of pothole-ridden miles, we arrived in Kampala with a rainbow of bruises more varied than the stamps in our passports. After a day of waiting for our next bus, we boarded the luxury liner to Kigali, which was much better than our trip to Uganda, except for the “American Boy.” Instead of the quiet roar of a diesel bus, which drowns itself out, we were treated to a Nigerian film about that blared loud sound from a cracked speaker for over 3 hours. The rest of the passengers loved the film but the “Welcome to Rwanda” sign, was a long awaited visual cue that this comedy/drama classic would soon end. When we finally arrived in Kigali, we needed to set up camp and get to business.

As a social entrepreneur on the go in East Africa, I would say the first step upon arrival into any new town is to establish an “office.” Step 1 is getting a local SIM card to slide into your phone. Africa is a “pay as you go” market for everything from shampoo to liquor, meaning you only have to purchase the amount you intend to use. (I discovered this last year in Tanzania when a women I wanted to photograph talked me into giving her some money for the picture and then proceeded to buy one Coke and one serving of gin in a small plastic bag which she quickly opened and poured into the Coke.) With phones, this means you can buy a phone number via the SIM for about $1 and then charge it up as you need it. Step 2 is finding a place to work. Electricity is a must, internet is a nice-to-have and a comfortable environment is a supreme luxury. We found office utopia in Kigali’s Bourbon Café at the Union Trade Center. I typically avoid such Americanized places when travelling abroad, but at this point wireless internet and overstuffed chairs seemed a reasonable balance to our bus rodeo.

We headed down to Butare meet a Dr. Ignatius Kakande, a Ugandan surgeon who produced a brilliant presentation on surgical challenges in Africa. I had only communicated with Dr. Kakande over email and he invited us to visit him at the University of Rwanda. Our intent in the 2 hour trip was purely to meet Dr. Kakande, but upon arrival, we were quickly sent to see Dr. Jean-Baptiste Kakoma, a Congolese doctor and Head of the Obstetrics and Gynocology at the university. It didn’t take long before our collective enthusiasm for helping women with fistula exploded into an impassioned hand-waving discussion of how we might work together to change the face of fistula in Rwanda. Our tour of the facilities revealed two young surgeons with some fistula training and experience who were both interested in learning more as well as a physical infrastructure facility in need of support. We met a few fistula survivors in the small and crowded post-operative recovery ward. This hospital in Butare handles a consistent, albeit small, flow of fistula patients and the entire staff seems to believe that significant expansion of activities is possible with a little outside support.

We excitedly took notes and reviewed the site thoroughly, noting infrastructure gaps and potential opportunities. Unfortunately, the Hospital Administrator was not in the office, which limited a full scale site analysis. But we did find out that EngenderHealth had visited Butare in May and having gathered all the info we could, we rushed back to our regional office (Borubon Café) to follow up with our friends at Engender.

After twenty four hours of departure delays, missed flights and mindless people-watching in airports, I finally arrived in Berlin, disoriented and in great need of a toothbrush. Seth in his usual high-energy, unrelenting O.F. focus immediately wanted to get to work. Although obviously exhausted, my adrenaline took over as we walked all over Berlin for last minute items and packed and repacked our gear a million times. That night, over a plate of cow (Seth is a huge carnivore and I am practically Hindu) and spinach artichoke tapas we defined our organizational objectives and flushed out our ever-evolving strategy for the summer.

We left the next day for Nairobi via Doha, the capital of Qatar in the Middle East. Our 12 hour overnight layover exposed us to an antiquated world of Arabic and African cultures that have been mixing for centuries through commerce. The airport was a diverse stage of hundreds of languages, with poor South Asian migrant workers, wealthy oil tycoons, western businessmen, and fully clad Muslims of African and Arab descent. The smells of body order and Indian spices that permeated the air and strange and beautiful faces provoked a sense of curiosity and intrigue to the unknown world we were embarking upon.

Despite months of planning, traveling to Africa on this type of quest is a nebulous affair. We had reached out to surgeons and health professionals all over the region but a solid schedule seemed to elude us. As soon as we hit African soil we were welcomed Dr. Westin Khisa, a fistula surgeon in Nairobi. Dr. Khisa is a short, smiling man with a hundred jokes in his pocket and a warm hospitable heart on his sleeve. Working with AMREF, he has helped build O.F. treatment capacity throughout Kenya. Seth met Dr. Khisa while in Geneva at the World Health Organization and our primary purpose in reconnecting with him was to pick his brain on how he and his team built this capacity. After a short tour of his office, Dr. Khisa invited us to an evening of masala tea (a black pepper and ginger spiced African tea) and fish sticks as we discussed maternal health in Africa and American politics with he and his colleagues (these Kenyans sure love Obama!)

We continued the conversation the following morning for a 7am breakfast. The doctors shared their deep sense of African society at the community, district, and national level. Kenyatta National Hospital (where they all work) is one of the largest hospitals in Africa and they are responsible for even the most remote patients in Kenya. Despite efforts to set up a formal network of referral hospitals, reliance on traditional medicine sometimes keeps populations of people out of the national health scheme. Nairobi doctors are seen by some local people as alien and these people prefer treatment by community health workers who they know and trust, but who sometimes have absolutely no medical training. To build bridges as outsiders, working in this area is a tricky task even for Africans. This discussion over breakfast helped us to understand the intricacies of working within tribal populations in African society and bridging the gap between rural and urban (read modern) medicine.

That night we took the overnight train to Mombasa, an ancient Afro-Arab trade port on the Indian coast. The rhythmic but loud thumping of trains usually keeps me from sleeping but this train was magic. I woke up at 7am, refreshed, ready to go and expecting to arrive in an hour with a full day. But for some reason we were stopped. Five minutes into breakfast, we learned that we had actually been stopped the entire night due to a carriage derailment about a mile up- comforting to know as we traveled in a carriage on the same archaic tracks. To kill time, we walked around Kibwezi, the small village that our waiting train had invaded. But as curious as we were about the villagers, they seemed even more interested in watching us. We made friends with unspoken words and nail polish and were finally on our way again.

Twelve hours later, we were greeted at Mombasa Railway Station by Dr. Jennifer Merry Othigo, a fistula advocate and surgeon from Coast General Hospital. Seth met Dr. Othigo for a few minutes in New York and had mentioned our upcoming trip to Kenya. Without hesitation, Dr. Othigo offered to host us and we were as excited for this experience as we were to discuss her success in treating fistula in the coastal region. Dr. Othigo has a deep understanding of treatment costs and she helped us develop a detailed patient costing analysis so that we could capture and categorize the components of a single vesico-vaginal fistula (VVF) surgery. While we had planned on at most two days of meetings, our delayed arrival and Dr. Othigo’s phenomenal African hospitality extend our stay through the weekend.

With extra time, we had a chance see the real Mombasa and to get to know Dr. Othigo and her friends and family. As Mombasa is a rich blend of Arab Muslim and African Christian societies, Dr. Orthigo transcends religious and cultural divides by working in partnership with the Council of Imams, an organization of Muslim societal leaders. This deep cross culturalism is pronounced in her personal life and we were invited by her close friends Zeitun and Said to a traditional Arab-Swahili meal in their warm and simple home. The magnificent food and Arab generosity highlighted the unceasing African kindness we had experienced since we landed on the continent. Though we were really beginning to grow comfortable in this coastal port, it came time to board the train once more for an overnight (hopefully) return trip to Nairobi.

Sun drenched cafés, open air cinemas, and the burst of applause roaring from a pack of rabid football (soccer) fans – even I can’t believe I am leaving Berlin at peak season. But duty calls.

After months of deep thought, broad conversation, and thorough strategic consideration, we at OperationOF are ready to take our little venture to the next level. For us, this means condensing the idealistic clouds of our Concept Phase into a tangible base of test cases that will define our Pilot Phase. In this pilot phase we will put some of our concepts into action, testing specific techniques in different environments to see what really works and what needs improvement. A successful pilot will not only teach us volumes, but it will also allow us to develop and refine a set of programs applicable to a broad set of situations. The design and implementation of the pilot is really the key to developing a highly scalable approach to treating fistula. (The first pilot program is focused exclusively on treatment, but subsequent iterations include and will eventually focus exclusively on prevention.)

Our concept is to build highly efficient and sustainable capacity to treat women with obstetric fistula. This means getting local African doctors the training and equipment they need to address the enormous and pent-up fistula demand. It also means working closely with hospital administrators to ensure that their organizational resource base and processes are sufficient to serve our cause without abandoning all the other good working being done by the hospital. In an environment of mind-boggling lack of medical capacity and infrastructure, it is important to design structures that keep hospitals balanced while also serving our cause.

With all that in mind, we decided to launch our first pilot in East Africa and will spend summer gathering information and evaluating potential pilot sites. Besides meeting with proven capacity builders in Kenya, Uganda, and the Democratic Republic of the Congo, we will be reviewing various hospitals in Uganda and Rwanda. Throughout the trip, we will also engage with various women’s empowerment organizations.

Besides gathering information and gauging fit, we will model capacity building/expansion and process improvement techniques for centers currently treating fistula as well as those with little or no presence in the space. We break the potential sites into two groups, which we describe as follows:

• Greenfield (less than 75 surgeries per year); and
• Expansion (more than 75 per year).

Throughout the trip, we will work to update the blog and send reports from the road, so check back often, or subscribe to stay updated!