It is with tremendous pride that i can report the outstanding success of the gambia ii project for the 2001 operation crossroa

Final Evaluation of the Gambia II project for the Operation Crossroads Africa program, It is with tremendous pride that I can report the outstanding success of the Gambia II project for the 2001 Operation Crossroads Africa program. Whereas the fieldwork of international development is sometimes politically sensitive, subject to moral ambiguity or differences of interpretation, the 2001 Gambia II team had an observable positive impact on public access to basic health care services in rural Gambia. Our presence there has already made a clear difference in helping to save lives, and we hold this to be an incontrovertible good. The success of the Gambia II project is due to the efforts and ingenuity of a remarkable group of people—the Crossroads participants, gifted, driven, diverse, and each destined to make the world a better place by being in it—and to the coordination and support of our African hosts and counterparts. A brief word must be said about each of the people most responsible for making our stay as comfortable and our work as productive as possible. Dr. Gibril Ahmed Jassy, the medical director of the Kombo clinics, was our host, mentor, and friend. Those who meet him quickly recognize him as a brilliant and capable man. Trained in the Soviet Union and widely traveled, he could easily have practiced medicine with the superior facilities and standard of living that are possible in Nigeria or elsewhere. It was a fateful trip home early in his career, when a local woman and her unborn child died due to complications in delivery, that convinced Dr. Jassy of the need for a clinic in his home community. Dr. Jassy told us that every doctor needs one patient that he will never forget. This was his—the case that changed his life. I think I can speak for all of the Gambia II participants when I credit the Crossroads program and Dr. Jassy with giving each of us the chance for this very kind of transformative experience. Both for those of us who aspire to be doctors and for those of us who will answer to other callings, Dr. Jassy’s example will remain a profound influence on our lives. Dr. Jassy is assisted by a Ghanaian teacher of agricultural science, Joseph K. A. Mensah (affectionately referred to as Joe Jassy), who serves as the financial administrator of the Kombo clinics. Joe’s vibrancy and exuberance were an unforgettable part of our time in the Gambia. One word of warning, however: Joe has neither any concept of the limitations of Americans’ financial means nor any qualms about asking them for gifts. We found we had to politely refuse to buy such items as CD players and plane tickets for him. This minor matter aside, Joe provided valuable guidance to our group and energetically contributed to finding solutions for any problem. Dr. Jassy’s nephew, Ebrima (or Basolo) was a close friend and a very reassuring presence for all of us, especially during our time traveling around the Gambia and Senegal. With six years’ experience working with American students in Africa, Basolo was indispensable in helping us to arrange transportation, obtain fair and reasonable rates from money-changers, taxi and bus drivers, and others who would tend to exploit foreigners in their country, and once even bluffed our way through border police who were attempting to extort a bribe. Dr. Jassy’s niece, Musukebba, deserves special mention for her personal devotion to the Crossroads group throughout our time in the Gambia. She prepared meals for us on a daily basis, assisted with washing clothes when asked, and brought a joy and sense of humor to our stay which would have been absent without her. With this glowing introduction, I do not mean to gloss over the hardships, frustrations, and shortcomings of our work in the Gambia, which have been many. These will be discussed in detail, along with recommendations for how future Crossroads groups might deal with these challenges. It is my sincere hope, as well as the expressed hope of our hosts, that the relationship between Operation Crossroads Africa and Dr. Jassy’s Kombo Clinics will continue. The obstacles our group faced in breaking new ground to forge this relationship will be considerably less for any who follow in our footsteps, and those who come in future years will be able to accomplish even more by building upon our foundation. Since I am preparing this document in the hope that it will be of some use to a future group of Crossroaders headed for the Gambia, I want to be particularly clear about the areas where I feel there was room for improvement in my own performance as group leader. On the whole I am probably more proud of my work with Operation Crossroads Africa than I am of any work I have done in my life so far. Still I am aware of some limitations in my effectiveness and I am sure that those who worked alongside me could point out others. I hope to be as honest as possible about these limitations so that one who comes after me can begin her work with the wisdom I lacked. It is a tragic irony that Americans who come to West Africa to affirm their common humanity with Africans and significantly help African communities sometimes find themselves the targets of many forms of envy, resentment, exploitation, and harassment. Female group members were frequently subjected to sexual harassment, which came to be expected in any urban area but also arose at unexpected times and places. All group members faced harassment from beggars or merchants eager to sell their products, but these were usually less invasive and easier to get rid of than the “sketchy guy” type who popped up everywhere we went. After some trial and error, we found that it was possible to save a lot of trouble simply by saying that the male group members were the husbands of the female group members. In all honesty, I must admit to some personal regret for not having handled this situation more proactively, either in mentally preparing group members for the harassment they would encounter or in deflecting the harassment of persistent hangers-on. I began with a “path of least resistance” approach, silently avoiding confrontation when possible and silently bearing the harassment when avoidance was not possible. In retrospect, I think this was not the best approach. I would recommend to future group leaders that they meet aggression with (polite) aggression, and actively defend the personal space and privacy of all group members. I would also feel I had left something out if I did not mention a common pickpockets’ trick which we encountered twice, once in Banjul and once in Dakar (neither attempted robbery was successful). The would-be thief approaches, seeming friendly, sometimes offering a bracelet or other small item for sale. He or an accomplice will then gesture to the intended victim’s shoes, as if to give a compliment on them. It is at this time that he pulls on the pant-leg of the intended victim, an action which pulls the pocket away from the body and makes it impossible to feel a hand slipping in in search of a wallet. Once the first step of the plan is recognized, it is easy to prevent the theft. Beware of anyone who likes your shoes. The final unpleasant surprise of our time in Africa was the sudden escalation of travel and accommodation expenses beyond what we had anticipated. At the beginning of our travel period, we had a surplus of slightly more than $500.00 (US) in our food and maintenance budget. Adding this to the $700.00 allotted for our travel week, we were very optimistic about our options for where to stay and what to see. Our optimism was premature, as it turned out, and on the group’s last day in Africa it became necessary for each member to contribute personal money in order to meet the expenses of our lodging, food, and transportation to the airport. I regret that I was not more proactive in handling this situation as it developed. The group entrusted Basolo with handling a portion of our money for the purpose of paying taxi and bus drivers, who universally gave a better price when they believed a Gambian rather than an American was buying their services. Unfortunately, this arrangement made it difficult to keep track of travel expenses (which turned out to be much higher than expected) as they were incurred, and to adjust our spending accordingly. The group traveled to Georgetown and to Dakar during the last week of our time together, and in both places the costs of lodging and food were (once again) greater than we had expected. By the last day of our stay, when it became obvious that the remaining group funds would not meet all the remaining expenses, the group leader was suffering from malaria and was practically useless in resolving the situation. I had been taking Lariam regularly, but caught the disease anyway. On the night the group would be flying out of Dakar, I had a fever of 103.5° F. The participants worked out a solution through their own initiative and self-sacrifice, which they did ably but should not have had to do. But of course I am getting ahead of myself. In order to explain the real heart of our experience, I must go back to the beginning. It has come to my attention in conversations with other group leaders that many Crossroads groups faced problems in starting their projects. In our case, we were delayed from even moving to our site. Our host, Dr. Jassy, was unfortunately under an obligation to be present at a cultural festival in the village of Kanilai for the entire first week of our time in the country. We appeared to be stranded at the President’s Award Scheme guesthouse in Bakau, perhaps for an indefinite “couple of days” of African time. It took considerable effort even to get in touch with Dr. Jassy’s assistant, Joe Mensah, and almost coercive pressure was necessary in order to arrange transportation to our site in Gunjur within an acceptable timeframe. Once we had arrived, we found we had no clear role or function to fulfill in the day-to-day operation of Dr. Jassy’s clinic. Dr. Jassy has been inviting medical students from the University of Alabama to observe and assist him each summer since 1995. Three Alabaman students were already at the site when we arrived. Today in the village of Gunjur there is another clinic (besides Dr. Jassy’s) less than one hundred meters away and closer to the central market area. There is also a very large Health Center, which is the primary health care facility for most persons living in Gunjur and adjacent communities. As a result, Dr. Jassy typically saw less than ten patients a day at his home clinic when we arrived. With a total of ten Americans on hand to “assist,” there was really very little work to be done. The Crossroads group began to explore other options for being of service to the community. Some of the participants were able to assist with dispensing prescriptions and other duties at the Gunjur Health Center. Dr. Jassy’s nephew, Ebrima, was a crucial link in making arrangements with the Health Center staff. Group members repaired the well in Dr. Jassy’s compound. The group began discussions with the principal of the primary school about the possibility of teaching classes part-time or assisting in classroom activities. Joe Mensah, who was then teaching Agricultural Science at the school, was very helpful in making introductions and arranging meetings with the principal. Dr. Jassy raised the idea of a few group members at a time going up to Royal Victoria Hospital in Banjul to observe and assist doctors there. Ultimately, it was not necessary to pursue any of these alternate projects because Dr. Jassy finalized arrangements to open a new branch clinic in the village of Sanyang. Our group relocated to Sanyang, where our real project would begin. The Sanyang clinic compares favorably to the site in Gunjur in many ways. It is larger than Dr. Jassy’s home-based clinic, able to accommodate two or three times as many patients at once. More importantly, it is located in an area without other health care facilities, where the extra capacity is not only desirable but in serious demand. The group’s living conditions also improved dramatically when we relocated to Sanyang. In Gunjur we had been staying in an unlit, unventilated room which stayed pitch-dark and uncomfortably hot 24 hours a day. The space was barely sufficient to contain our beds and our supplies. These conditions, were they imposed upon a human being as punishment for a crime, would be considered inhumane. Upon moving to Sanyang we enjoyed the comfort of windows. Although the total square-footage available to live in was not much greater, the difference in light and ventilation was an indescribable relief. Thanks in part to money donated by the Crossroads group from our food and maintenance budget, the Sanyang clinic also includes the benefits of drinkable running water, with a shower and a flushing toilet. These stand in contrast to the unsanitary well water and shallow pit latrine at Dr. Jassy’s compound in Gunjur. When we first arrived at the Sanyang clinic, we took part in a number of construction and renovation projects necessary to prepare the building for use—painting the fence, assisting the plumber with installing the toilet and shower, and putting a linoleum floor into our own living space. Once the clinic was formally opened, our group divided into two teams who alternated between observing the doctor and performing regular duties for patients. We learned a great deal from observing the doctor as he saw patients, made diagnoses, and wrote prescriptions. We were not only taught how to recognize different kinds of illness, but uniquely benefited from Dr. Jassy’s wealth of experience, his countless anecdotes, and his amazing rapport with patients. This last aspect is perhaps the most important. Dr. Jassy always emphasized the psychology of healing and the necessity of preserving the patient’s confidence in the doctor. We were trained in a variety of tasks to extend the clinics’ services to patients. Although all of us were hesitant at first and unsure of our ability to perform these duties, by the completion of our project we did the following routinely and with confidence: 1. Taking patients’ blood pressure, temperature, and pulse. 2. Reading and administering prescriptions written by the doctor, both tablets and intramuscular injections. Typically these were injections of Chloroquine (for malaria) or Gentomycin, Procaine Penicillin, or crystalline penicillin (for a variety of infections) given in the upper arm, thigh, or buttock, depending on the age of the patient. 3. Dressing wounds. Gauze, hydrogen peroxide, and antibiotic ointment were constantly running out, and both the Crossroads medical kit and the personal medical kits brought by the participants were used for patients and quickly exhausted. Some improvisation proved helpful. Dr. Jassy taught us that procaine penicillin, mixed with vaseline, can be substituted for antibiotic ointment. On one occasion it was proven that a sanitary napkin can be adapted for use as a bandage on a large, open wound. In addition, we observed and assisted to a limited extent with two surgical procedures. The first was the circumcision of a 16-year old. The second was a hydrocelectomy (draining and inversion of a swollen testicle) on a 70-year-old. Our function in these operations included such tasks as handling surgical tools, holding a flashlight for the doctor to see by, blotting up blood with gauze, holding forceps to assist the doctor in tying sutures, and cutting off the loose ends of sutures once they were tied. The benefits of practical, hands-on experience like this for pre-medical students are obvious. Operation Crossroads and Dr. Jassy have clearly provided a unique opportunity for the participants of the Gambia II project. However, one question naturally presents itself. It must be said that the practical duties we learned to perform would not have been possible for us in the United States, where all aspects of medical practice are under tight legal controls. What, then, is the moral justification for our involvement with such tasks in Africa? The answer is that we were the best alternative available, and we had a real beneficial impact on the quality of public health care in the Sanyang area through our contribution to the operation of Dr. Jassy’s clinic. In the Gambia, where the shortage of educated health care workers is so severe, even the basic familiarity with medicine we brought with us from our own educational backgrounds made us a valuable addition to the staff. Dr. Jassy recruited a number of the residents of Sanyang to be nurse-trainees. These trainees were all eager to help, but dangerously uneducated. With low levels of literacy and math skills, it was challenging for them to learn many of the tasks we picked up quickly. Having little familiarity with biology and no concept of the word “sterile,” they were prone to re-use unsterile needles, leave them uncapped and scattered across a desk where anyone could easily suffer an accidental puncture, and generally fall short of accepted safety standards. Our presence in the clinic, working alongside the nurse-trainees and insisting on proper safety procedures, certainly may have saved lives. So that the reader will not be terrified that any future Crossroads group will run the risk of being pricked with needles carrying HIV or Hepatitis B, let me offer some reassurance. Although there was a period of a few days when our group was very concerned about the possibility of unsterile needles carrying infection from patient to patient (or, in an unlikely but even more frightening scenario, patient to health worker) these concerns were put to rest by the time we left the clinic. Both our repeated warnings about the safe handling of needles, and the warnings given by Dr. Jassy, seem to have driven the point home for the trainees and resolved the situation. In any case, the trainees had literally just come in from the village when we met them, and a Crossroads group that follows us in 2002 will meet them after a year of training and practice under Dr. Jassy. I can say in good conscience that safety issues at the Sanyang clinic are not out of proportion with those of any public health care facility in the Gambia, and absolutely should not preclude the continued involvement of American volunteer workers. For one final example of why I am so proud of the work of Operation Crossroads with the Kombo Clinic in Sanyang, I would like to tell one story in a very abbreviated form. There were two occasions on which the doctor was back at his home in Gunjur and a patient came to the clinic with symptoms indicating a need for emergency treatment. In both of these cases, Crossroaders were in the position of being able to recognize the seriousness of the situation when locals and clinic staff did not, and it was through our insistence that these patients were transferred to Royal Victoria Hospital in Banjul. In both cases, the clinic staff had been inclined to simply leave the patients to rest until the doctor came the next day. The consequences of such inaction might have been dire. In the second case, a patient with incapacitating stomach pains gave us cause to fear appendicitis. The doctor in Banjul ultimately made the diagnosis of a peptic ulcer, but our concern was justified by our experience with the first emergency case. This one occurred around midnight, after the group had all gone to sleep. A young man was brought in, unconscious, his body completely rigid. His friends said he had been ill for five days and now he could not be woken up. The clinic staff, unsure what to do, asked for our assistance. It was very fortunate that every Crossroads group was given a copy of the book Where There is No Doctor along with their medical kit. I hope that Heather Sponsel will not mind my mentioning her name, for it was she who had been reading Where There is No Doctor, and was able to diagnose the patient’s meningitis and prescribe an antibiotic. (The preferred treatment is with an injection of crystalline penicillin, but at that time the clinic had only procaine penicillin, and this is what we administered.) The patient showed signs of improvement during the long journey to Banjul, where Heather’s diagnosis was confirmed by a doctor at Royal Victoria Hospital. I think it would not be unfair to say that Operation Crossroads saved a man’s life that night. A word of advice for any future Crossroads groups on a medical project: study the book. I don’t know if this brief paper can possibly express the joys, struggles, and rewards of our experience in the Gambia. I have never been prouder of any six people than I am of Noelia Chung, Kelly Smith, Bonnie Durgin, Heather Sponsel, Danielle Woods, and Andy Cha. I am proud to have worked with them and I have the strongest possible confidence in their futures, a confidence built upon the strength of character, compassion, humor and wisdom each of them has demonstrated in my presence. I can say without reservation that, all of our difficulties and trials notwithstanding, the Operation Crossroads Africa program has found its truest expression and the fulfillment of its mission in the 2001 Gambia II project. May our success be echoed and improved upon for many years to come.


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