FEB-A-13
A PRIMER ON
WORKING WITH PEOPLE IN
RELATIONSHIPS MORE IMPORTANT THAN ACTION;
INTRODUCTIONS OVER SUBSTANCE;
PATIENCE OVER PRAXIS;
COMMISERATION
OVER SOLUTION;
UNDERSTANDING OVER KNOWLEDGE:
“AFRICAN
FEMINIZATION OF AMERICAN
MEN OF ACTION”
February 7, 2004
Our presence is more encouraging than the process we seek to put into action.
In fact, it is doubtful that any of the processes which we as over-active Americans on a surgical “hands on” mission of things we had hoped to “do” would be sustainable after we left, given the different mindset than that of the process oriented American model of actions taken. The Deming Philosophy of a continuous quality improvement is not an ideal fit within this context as much as we might like to see it at work here in improving the rather tawdry state of the Group Hospital of Hargeisa General---a” Hospital in Name Only” according to even one of its own staffers! We have come here with equipment, supplies and surgical skills and capabilities, even if fledgling in some instances, and are eager to be getting about doing something, and “making it all happen.”
This is not a good fit in the “Primer of Working With African People” which I am listing above. The American proclivity is to move out into action and get the cargo moved. We then keep score of the number of patients treated, operations performed, and individuals trained to carry on. They are not doing this “process analysis” however mystified they may continue to be about how it is that the American model seems to get magic results. But, they would be unwilling to adopt the methods needed to achieve those results. Hence the frustration of the team all gathered ready willing and able to get to work, on an “off” Friday with an essentially “abandoned hospital” filled with neglected patients who rather expected to be left ignored in sleepy isolation without a care plan for moving them forward. We have come from the wrong model and are trying to apply it to a very different African mind-set which might humor us a little to continue to attract our interest and hold on to our continuing attention, but who are not likely to develop an American medical hyperactive work ethic to achieve results without the similar unhealthy process.
If the American medical model were forced into an African application, there might be a few beneficiaries—those few patients who got services relatively efficiently, but at a cost of alienating the social and cultural network into which it is a poor fit. They are most hospitable, and seem eager to get the stuff and expertise we bring, but applying them methodically in problem solving is not their objective. It is rather the relationship—“Getting to Know You” as I had described it in a prior chapter—not the action they are after. Recall the theme song for all solutions proposed to be universal in this setting: “yes, but, it is very difficult.”
“Difficult does not mean impossible, so let’s get started.” OK, but the driving motivation is absent and the process will disappear when you leave. “But, you cannot just sit there and let this situation deteriorate further and let these people go untreated and die!”
“Oh? We cannot? Just what do you think has been happening for millennia before you got here and will continue on after you leave? We did not inflict these circumstances you see imposed upon us, and we have to accept the context in which we work and cannot transform the whole society around us, but must accept what is the given. That is why we have no tension of unfulfilled expectations, since that is the way it is around here.”
This African fatalism is a well-practiced defense that is quite adaptive. It serves them well in preventing the frustrations we are feeling right now, since accepting the unacceptable and not railing against reality is an easier way to live. It may ill-serve the individual patient afflicted at the moment, but, they are also sure that they are ultimately not going to be rescued from mortality and suffering, and adapting to it has been a very much more useful way to live a life unburdened with “critical care.” The obligation that “there is something we must be doing about this” is excused up front, since, after all, we all know that “It is very difficult.”
Our services here are not a product that can be delivered that would have much impact on the community after we have left—or, for that matter considering the numbers—for very much while we are here. Efficiency is not a primary target. Accommodation is.
It is not so much money as mind-set.
If the entire gross national product of the USA (the largest economy the planet has ever seen) were donated to Africa as a solution to its problems, it would disappear without a trace within a generation and cause insurmountable problems beyond those already afflicting it. If Mayo clinic were picked up from Rochester Minnesota and dropped onto the Hargeisa General Hospital compound, “what interesting ruins this will make,” to quote an observation once made while surveying the architectural splendors of Riyadh in the Nejd Plateau of Saudi Arabia.
A service to people must be rendered in sympathy with the culture which is to benefit from it. A product that is “standardized,” meaning in the Deming terms ‘Minimize Variation,” is the antithesis of what is needed here in which “one size does not fit all” from a mass produced process. So African health care is not “delivered” from America in 167 kilograms of suture-packed duffel bags, nor in a George Washington University curriculum. Nor do they really expect this to happen, despite such an unreasonable request. Rather, as with their own people with whom they meet with prolonged formal sympathetic introductions, often without ever “getting down to business,” they are commiserating, sharing an experience of shared humanity in a cruel world of uneven distribution of suffering and resources. Morbidity and mortality are common experiences. Let’s see if there is a way we can accommodate them to minimize their stressful impact on all of us who must keep on going forward, despite the environmental fact that we both recognize: “It is very difficult.”