Searching for Susu – part 2

by Bill Nelem
April 2008


The search for Susu has become a quintessential part of this trip to Africa for me. In part, the journey has become personal, in part, metaphorical, as you will soon discover.

Being charged by Rosemary to find Susu, I imagine myself embracing him and presenting him with a new bicycle. I imagine his surprise and excitement that Rosemary, who hasn't seen him for 32 years, still cares enough to make this gift happen. In my mind, I see him mounting his bike, male dog style, and riding off in typical African fashion – head high, spine straight, arms outstretched, swerving to avoid potholes as he went.

But, like so many hopes and aspirations in Africa these days, this meeting was not to happen.

Susu is believed to be dead. As they say in Zambia, he's late.

Hearing this news from John Jellis, I am surprised by the sudden sense of sadness that overwhelms me. I find myself grieving intensely for a man I've never met.

As metaphor, the news of Susu's presumed death triggers my grieving for all of Africa.

Why should 70% of all of the world's HIV/AIDS cases be born by Africans?

Why should sub-Saharan Africa suffer a 4-fold increase in the incidence of Tuberculosis in the last 8 years?

Why should hundreds of thousands of African children die each year to quench the collective thirst of the malaria-carrying anopheles mosquitoes?

Being partitioned by avaricious colonizing nations a century ago, without thought or care for pre-existing indigenous sensitivities, why does Africa suffer such post-colonial conflict and torment when finally given self-government?

Truly, 'The Shackled Continent' as Robert Guest writes in a book by that name. Read it.

Susu was about 50 years old when Rosemary's father sold the remaining part of their farm in 1976. Six years ago, at the age of about 75, in failing health, Susu returned to his village to die, accompanied by his wife and by Alison, their son. John has not had direct confirmation of Susu's death, but he can't imagine him still alive given his poor condition when he returned home so many years ago. John does not know the whereabouts of Susu's village. The trail ends.

We can only hope that his wife and son are happy and well.

I return a second tine to Rosemary's childhood farm to visit John and Jane Jellis, on this occasion with Linda Hawker, Family Physician, Gary O'Connor, Orthopaedic Surgeon and Kim Lefevre, Neurosurgeon, all of Kelowna.

Hillary Robinson, now retired British Orthopaedic Surgeon is still visiting there working with John.

As John drives us about his farm in his new Land Rover, his life story unfolds in reverse chronology.

We stop at an artificial dam that he created many years ago to trap the seasonal rains and to enhance the bird life. Picnicking and fishing are John's daughter and son, their respective families and some friends.

They celebrate the birthday of one of John's grandchildren. He revels at the 'Hello Grandpa' greeting.

His daughter manages the 50 or so horses on the property that sustain Zambia's only polo ground. His son, a man for all seasons, manages the cattle farming operation.

John's love for the native habitat and ornithology is clearly apparent.

We cross through a fence, entering Rosemary's original homestead farm.

The Land Rover swings onto a well-maintained airstrip. A brand new hangar houses a gleaming late model Cessna 206. The Beechcraft is away for it's annual inspection.

Supported by the Dutch Government, John operates 'Flyspec', an initiative he began in 1982. Along with Zambia's only Plastic Surgeon and his present and past Orthopaedic trainees, John flies regularly to a dozen or more rural hospitals to consult and operate on patients scattered all over rural Zambia.

In 2007 alone, they flew 67 missions, seeing nearly 3000 patients in consultation, performing about 900 operations. We learn that Zambia's rural hospitals were built in earlier times when they anticipated adequate professional staffing. Now desperately short of physicians and nurses, the countries medical system struggles to cope. 80% of graduating physicians and 60% of nurses leave the country for better pay and lifestyle elsewhere.

John has the only sustainable rural health programme in Zambia.

The cost to the Ministry of Health and the patients for this model service?

Nothing, apart from providing access to otherwise unused surgical theatres, idle for want of surgeons to use them. He flies in all of his surgical hardware as well as the disposables such as dressings and sutures.

Having completed his Orthopaedic training in 1972, John immigrated from Britain with his wife Jane, becoming the first Chair in Orthopaedic Surgery the year Zambia started their medical school.

Now 72 years old, and working full time in his 'retirement' he can look back on a truly remarkable career. Like Chifumbe, he is another of Zambia's iconic medical characters.

Within the context of his specialty, John has found a way to solve many of Zambia's health care challenges.

Early on in his career, he saw the need to provide a source of added income to retain physicians. With Italian aid, he established the

Zambian Italian Orthopaedic Hospital that allows some private practices whilst providing free care for all children in need.

Also in his early years, he founded an Orthopaedic trust that he uses to offset patient and equipment costs.

During his career, he has trained several Orthopaedic Surgeons. His is the only specialty never to have a graduate leave the country. Zambia must have the only Orthopaedic training programme in the world that requires pilot training as a pre-requisite for entry!

His strategies for education, training, retention and rural health are widely recognised and respected. The only problem is that no one else seems to have his skills and his passion.

We were amused to hear that during one of his rural fly in clinics, he had to break his Orthopaedic list to perform a Caesarean section when no one could be found to do it. We expect nothing less from Gary when he returns to Kelowna!

In my disappointing search for Susu, quite serendipitously, I stumbled onto the gemstone of John Jellis.

Susu is looking down and smiling. As an expert at riding bikes, he thanks you Rosemary for your love and your concern.

Mongu Matters – More than I first thought

Significant synergies are emerging for us with respect to Zambia's Western Province.

The fact that many of the activities are being matched from British

Columbia, our western province, is quite likely by complete chance.

However, I recognize serendipity when I see it and I know how to capitalize on it.

Mayor Shepherd and her Kelowna City Council recently signed off on sister city status for Kelowna and Senanga, Western Province's second largest town.

VIDEA, the Victoria based NGO, with the support of KaZ, the Kelowna Zambia community support group, are providing aid and infrastructure for Senanga.

As part of our now operational Memorandum of Understanding between UBC Okanagan and University of Zambia, and at Margaret Maimbolwa's suggestion, Jessica and Lianne will be going to Mongu, Western Province's capital town, to teach at the community nursing school.

If we are to put two medical/surgical/nursing teams on the ground in rural Zambia for a month each year, why not deploy them in Mongu and Senanga and create a combined synergy with the other BC based activities?

'A comprehensive collaboration between Canada and Zambia's respective Western Provinces.'

The theme will play out well with the media, and, perhaps with fund-raisers.

I haven't forgotten Rebeccah's exhortation that all activities must begin and end with 'evaluation'.

After luncheon with Lusaka Central Rotary, I head off to Mongu again.

The details regarding Jessica and Lianne's tour remain incomplete. Mr Alfred Mandona, the Principal of the Lewanika Nursing School was away when I visited last. I need to compete J&L's arrangements.

The Rotary lunch runs late, so the 6-hour drive to Mongu will put me there after dark.

This time I see live elephants on the road, rather than their evidence of tree destruction and their dung. The women are again cautiously washing clothing on the river's bank.

Again, the same guard at the game reserve checkpoint stops me.

Having neither fish for the market, nor sisters for the next village, he waves me through. Judging from the width of his smile and the vigour of his wave, he's obviously forgiven me for not hauling his smelly fish last time I passed this way. I'm most recognizable. How many white men travel this stretch of road alone in any given month, or year for that matter?

Dusk descends whist I'm still some 100 kms from Mongu. With blinding effect, the sun sets in the west directly in my line of view. I apply the window wipers to clear the grease from the dead moths and flying ants that have splattered on my windshield during the day. To my dismay, with the first wipe, I learn that there is no water or soap in my window washer bottle. Visibility is completely lost amidst a blur of fragmented wings and smeared insect oil.

Arriving late at Cheshire Home for Physically Challenged Children in

Mongu, I receive another warm handshake from Sister Cathy, and the key to my now familiar room.

As Western Province suffers from yet another power outage, I dine with the nuns by candle light, red wine in hand, capturing one of those unforgettable 'Out of Africa' moments.

Jessica and Lianne, they are all primed and pumped for your arrival in Mongu. Andrew Silumesii, Alfred Mandona, the other two teachers, the four clinical instructors and all of the students will receive you with open arms.

With a copy of the now famous Memorandum of Understanding in his hand, Mr Mandona, without prompting from me, proceeds to interrupt a first year student lecture in progress. He marches me up to the blackboard and announces to the startled and surprised student body;

'We are embarking on an international collaboration.'

A prolonged 'oooooh' can be heard arising from the students, followed by a respectful silence.

Some jaws hang in disbelief. Some eyes squint, wanting more information.

The drooped shoulders of some express perhaps a little anxiety. But, make no mistake, all of the students are riveted by this news.

'You're going to love your Canadian instructors', I enthuse.

As Mr Mandona and I leave the classroom, the entrance door still open, an outburst of chatter and the clapping of hands tell me that the international collaboration already has it's beat!

Margaret's on to it Beccah. She has an evaluation plan in mind with

Respect to the nursing school status prior to our nurses' teaching activities there. She wants to talk to you about it.

Cameron O'Connor, should you choose to accept the challenge, there is a 6-week volunteer job awaiting you in Mongu. Your assignment: Teach computer skills to the first year nursing students.

The good news, Cameron O, is that there will be two very attractive young Canadian nurses on site.

The bad news; you'll all be staying with the nuns!!

More later, Bill

The places you go – the people you meet

by Bill Nelem
April 2008


By far the three most influential people we've met are Dr Stephen

Simukanga, the Vice Chancellor at the University of Zambia, Dr Puma, the Deputy Minister of Health, and Dr Peter Mwaba, the MoH appointed administrator of the University Teaching Hospital. Peter is also charged with development, capacity building and infrastructure support in rural Zambia.

All are personable, accessible and interested in who we are and what we can potentially do in support of Zambian health care.

The UBC Okanagan UNZA Memorandum of Understanding opened doors everywhere. I had to go to the Supreme Court to get more copies of the MoU notarized because they all wanted multiple copies distributed to their various departments.

Even though the MoU was signed at the dinner we held for the occasion, I was summonsed to attend the VC's office the next day just to 'chat'.

Holding a map of Canada, the VC asks me to show him the whereabouts of Kelowna. How big is your town? What industries do you have? What is the 'Okanagan' add on to UBC?

How do you run two campuses under the one UBC flag?

Then with the MoH hospital administrator and the Deputy Minister of Health:

'If we bring a doctor/nurse team to work a rotation in a rural regional hospital, can we bring a documentary team to film and record the experience?'

'No problem - the Minister will issue a Directive.'

'What about the logistics with respect to transport, supplies, etc, etc.'

'No problem - the Minister will issue a Directive.'

Other significant contacts include Dean Mulla, Margaret Maimbolwa, the physicians and surgeons we met, the Mongu connections including the Regional Secretary for Western Province, Mr Mandona, the Principal of the nursing school in Mongu, Dr Stewart Reid, the Canadian Internist working at CIDRZ, an Alabama based NGO with a $15 million annual budget.

Emily at Women for Change, the NGO supported by VIDEA and KaZ is an important connection because she is so well connected as to how things work within the rural and urban communities. She's also a fierce and persuasive local negotiator for almost anything one might need at the grass roots level.

Of course, we always triangulate everything through Professor Chifumbe Chintu, my former medical school classmate! In all matters, it's always Chifumbe's call.

I’ll be off to Mongu again soon – Bill.

Searching for Susu - Part 1

by Bill Nelem
April 2008


I'm not sure exactly when Rosemary left Zambia for England and then Canada, but it was probably in the 1970's.

Born in Zambia, she lived as a child with her family on a large farm on Leopard's Hill Road, some distance outside of Lusaka.

When her parents sold the farm, it was divided in two parcels. I don't know who bought the larger part of the farm along with the original family house, but Dr John Jellis and his wife Jane bought the smaller part. Jane and John lived initially in a summer house that later burned down. Rebuilt, a newer house now stands on the ashes of the old site.

Rosemary remembers that Susu was the cook employed by her parents. Susu and his wife had a son called Alison.

Knowing of my upcoming trip to Zambia, Rosemary charged me to find Susu and, if he is still alive, make sure that he has a bicycle. If Susu is dead, I am to find his wife. If she is dead, I'm to find Alison, and to make sure he has a bike.

As I set out to find Susu, I'm about to discover more about Zambian health care, past and present, than I have during all of my visits and interviews conducted over the past three years-and that includes my many visits with Chifumbe.

All I know about Jane and John Jellis is that they have a post office

box in Woodlands, and that they live somewhere out on Leopard's Hill Road on part of the land where Rosemary grew up. I don't have a street number, nor can I find a telephone number.

Well, for starters, no one lives in a post box - scratch that.

Discovering Leopard's Hill Road on the map is easy.

I start by driving out of town.

It teems with people walking, with cars, bikes and trucks. I notice that there are no street numbers. That's probably why I have no street address for Jane and John.

An occasional building displays a business name, but otherwise there are precious few signs. Along the road, there are what look like farms or small estates. Some have gated entrances, but none have name signs. At some one must enter only with prior appointments, but there are no clues as to how one might make an appointment. '

Beware of dog' signs abound, as do stray dogs.

The road heads straight out of town. Not surprisingly, the traffic lessens as one proceeds. After many kilometres, the paved road gives way to dirt. The two-lane dirt road gives way to one lane. The pothole score rises from a 6 to an 8 - and then a 9!

Finally, whilst circum-navigating a particularly confluent cluster of potholes, the car shudders, and my left front wheel falls into a deep hole. My front axle comes to a grating rest on a rock. I am now pot-holed out at 10.

At the outset of this journey, throngs of people crowd Leopard's Hill

Road. Now I'm alone. No one is to be seen anywhere.

Knowing Africa, I am assured that faces will appear from somewhere soon.

First imagined, then done. Four young men bound along the road on foot, clapping their hands, laughing and pointing to my left front tyre.

I laugh with them.

One hefty heave from these lanky lads and I turn back to Lusaka. This is the end of Leopard's Hill Road for me!

Just as I regain the paved road, I see a sign that I missed on the way out, too busy dodging potholes, no doubt. 'Ann's Books'.

I surmise that Ann must be an educated person if she sells books. Maybe she will know of the Jellis house. Beside the main book sign is a smaller sign, 'Beware of Dogs'.

I approach Ann's house. Four large Rhodesian Ridgebacks, growling, barking and gnashing their teeth, surround me. I stay in the car.

The house door opens, and Ann appears. She clicks her fingers and the dogs are tamed. She is an older white woman, perhaps eighty. Her long hair is uncombed. As she walks towards me she limps, her left ankle wrapped ineffectively in a tensor bandage. She wears a loose smock, open at the front.

She speaks with an English accent; 'Ah, Jellis. About a kilometre back to town, Chifwembe Road, turn left, go four kilometres. You will see a sign on the left - the Lazy J Ranch'.

As I enter the farm where Rosemary once lived as a child, I see why she has such fond memories. On the right is a dedicated sanctuary. Straight ahead, I see a football pitch, a polo pitch and stables for 50 horses.

Jane greets me and introduces me to Hillary Robinson, an Orthopaedic Surgeon out from Britain to help John. John rises from his afternoon nap, and it dawns on me that I'm about to meet another of the country's iconic medical figures.

I know that I'm still searching for Susu, but my lessons on Zambia's health care history and present status are about to begin.

To be continued in ... 'Searching for Susu - Part 2. Bill.

Chifumbe Chintu – The Professor!

by Bill Nelem
April 2008


I first met Chifumbe in 1962 when we enrolled as classmates in Medical School at the University of Toronto. He had come from Northern Rhodesia where they had no Medical School at the time.

In 1963, four events occurred that were relevant to both of us.

First, we both passed our exams and moved into second year!!

Second, I was playing rugby for U of T at the time, and I was appointed to put together a track and field team from Medicine to compete at an inter-faculty track meet. We were a motley crowd with little apparent talent. I urged the lithesome Chifumbe to join our medical team.

'No, I'm out of shape, I'm not fit, I haven't run for a long time'

Chifumbe responded.

But I persisted, and Chifumbe did run.

In fact, he ran and he ran and he ran. I can't remember now how many races he entered, but I do remember that he was unbeaten in any race he ran, setting two university middle distance records.

He went on to train with the Canadian track team. At the Olympic

qualifying trials, Chifumbe won two middle distance races setting

Canadian records. The coach wanted him to compete in the Olympics for Canada. But some bureaucrat in Ottawa who noted that Chifumbe had entered Canada on a student visa blocked this request. A petition was sent to the Minister in charge of sport at the time. The application was lost in the giant hairball that is our Federal Government.

His home country did not have an Olympic strategy at that time, and was not able to send him.

And so it came to pass that the fastest middle distance runner in Canada at the time did not go to the Olympic Games. His friends were thoroughly aggravated, to say the least.

Third, Sir Alec Douglas-Home, the British Prime Minister in 1963, announced in the House of Commons that Northern Rhodesia would be released from the Central African Federation, paving the way for the country's independence. Thus, the following year, Northern Rhodesia became the sovereign state of Zambia. Chifumbe became a Zambian citizen, a First Zambian so to speak. His pride in his newly formed country would take him home one day once he completed his training. He committed himself to serve his country and his fellow citizens. The United Nations would one day award him with a medallion recognizing his contributions to medicine in Zambia and all of Africa. Zambian President Mwanawasa recently honoured him in a special ceremony, an act akin to our ‘Order of Canada’.

Fourth, on a fateful day in 1963, Chifumbe and I were attending a lecture at the Medical School. Professor Ritchie was giving a lecture in Pathology on Cancer of the Esophagus. He was a dour, autocratic, humourless New Zealander. He had a stunningly pretty wife and none of us could even remotely imagine what she must have seen in this overbearing man.

The day's events were memorable for two reasons, both of which I can remember as if they occurred yesterday.

First was the content of the lecture and second was an event that everyone alive at the time will relate to.

Now, a Thoracic Surgeon having performed hundreds of esophaheal cancer resections during my career, I remember my Professor of Pathology's words every time I begin to operate on an esophageal cancer patient.

With his sombre Kiwi accent, he said that 'cancer of the esophagus is not really such a bad cancer, it's just that it is located in such a bad location. Unlike other gastrointestinal structures, the esophagus has no serosa. Accordingly, esophageal cancers have one less barrier to prevent its spread. This disease has an unfortunate propensity to spread quickly to the gastro-hepatic and gastro- esophageal lymph nodes.

Surgical removal is fraught with technical difficulties and surgery is associated with a high incidence of complications and a high mortality rate'.

Forty-four years later, I can attest that everything Professor Ritchie said at the time remains true, with the possible exception of lower surgical mortality rates!

What was the other event of the day that was so memorable?

As the lecture drew to a close, the door to the classroom swung open and the janitor whom we knew well burst into the room. Professor Ritchie was indignant about being interrupted. Nobody, I mean nobody, ever disturbed this alpha male.

'President Kennedy has been assassinated!'

Professor Ritchie, Chifumbe, our classmates and I sat in silence. After what must have been a duration of several minutes, the Professor quietly folded up his lecture notes and tiptoed out of the classroom. The janitor and my classmates continued in silence for several more minutes, no one knowing what to say or what to do.

I went on to train in General and Thoracic Surgery, whilst Chifumbe went to Toronto's Hospital for Sick Children to train in Paediatrics.

Now fully trained, Chifumbe returned to Zambia shortly after the creation of the Zambia's only Faculty of Medicine and the building of the University Teaching Hospital (UTH).

Being the only certified Paediatrician in the country, he became the Professor of the fledgling Department of Paediatrics.

In the 1970's he went to Japan and presented the case to Japanese

foreign aid that they could assist in the building of a Paediatric ward

at UTH. They did. The ward today stands as a monument to Chifumbe.

A dozen or more years later, he returned to Japan and presented the case for a Neonatology ward. Again, he was successful. Now there is another monument to Chifumbe where hundreds of critically ill neonates owe their lives to him.

If you perform an Index Medicus - Pub Med search on the Internet, and key in 'Chintu CR', you will be flooded with the titles of several hundred articles that he has contributed to the medical literature during his career.

He was strategic in his planning. Collaborating with research teams from the US, Canada, the UK and Europe, he made his burgeoning Paediatric practice available to research, and his international recognition soared.

He has published on the state of Zambian Paediatric Oncology, Paediatric TB, Paediatric HIV/AIDS, the status of orphans, and a host of other relevant topics.

At different times he has served as the Professor of Paediatrics, the

Dean of Medicine, the Vice Chair of Zambia's Anti-Corruption committee, the UN appointed Chair of the Pan-African Ethics Committee, and the list goes on.

He has three children. A daughter is trained in Paediatrics and works for a Zambian NGO. A second daughter is a Rhodes' scholar studying Economics at Oxford. A son is studying computer sciences in New York.

Three years ago I went to Zambia to find Chifumbe. I am the only classmate to have done so. This initial visit launched my desire to

pursue humanitarian work in Zambia.

Chifumbe is a revered icon in Zambia.

Recently, when visiting very rural Mongu, the hospital's Executive

Director was giving me a tour. Spontaneously, he said; 'Professor Chintu recommends this treatment with those patients. Professor Chintu recommends those treatments with this patient.'

When I told the Director and his entourage that I was a classmate of

Professor Chintu, I found myself walking on reflected water, such is the respect with which Chifumbe is regarded even in the most remote and rural parts of Zambia.

I am honoured to list him as one of my friends. He is a Pan-African icon, a reputation he justly deserves.

UBC Okanagan - University of Zambia - Memorandum of Understanding - Signed

by Bill Nelem
April 2008


After many months of hard work by Gene, Alaa, the two Joan's along with Dean Mulla and Vice Chancellor Simukanga, the MoU between UBC Okanagan Faculty of Health and Social Development and the Faculty of Medicine at University of Zambia, has been officially signed.

At a dinner party where we hosted 11 Zambians, including the Dean and the VC, amid flashing of cameras and much hoopla, the signing took place, using a UBCO pen(!).

I was just the courier in this process, but happy to play my role.

Much credence is given to MoU's here. Ours is not the first they've signed, nor will it be the last.

For them, the document means more than a casual offer to collaborate, it conveys a commitment to work with them in a productive way.

For us, it provides a flag around which we can rally people ideas and resources.

The fact that all the important dignitaries without exception showed up for dinner means that they see promise with our MoU.

Also, not lost on their Dean and VC, is that we have had some immediate success thanks to the planning that has gone behind the scenes by Gene, Alaa and the UBC Okanagan Faculty of Health.

Returning to Canada with Linda, Gary, Kim and I is Dr Margaret

Maimbolwa, the Assistant Dean of Medicine, a nurse, also head of their nursing school. Margaret will spend three weeks in Kelowna working on 8 different initiatives within nursing.

Gene has circulated an agenda that looks quite daunting. Did you know that it takes 7 or 8 years for a degree nurse to graduate in Zambia for want of an integrated curriculum?

Well, with some idea sharing and some curriculum support from

UBC Okanagan Nursing, Zambian nurses will soon have a 4-year degree programme!!

Given the high attrition rate over the 8 years it takes to complete here, I suspect that we'll double the nurse graduates within a few years.

The other immediate success we've had is with young Donald Kalolo. He's the Chief Pharmacist at their newly opened Cancer Hospital that's attached to the main University Teaching Hospital in a manner very similar to our cancer centre.

Laurel Kovacic has been helpful in getting Donald a membership in the International Oncology Pharmacy Association.

Concurrently with his full time job, he's doing a Master' degree in

Public Health. His thesis is to develop a palliative care model that he hopes will one day become national policy for Zambia.

Under the umbrella of our MoU, Donald is attending the annual international pharmacy meeting in California in June and then coming to Kelowna to do planning exercises with Carole, Barb and others at UBC Okanagan as well as with our KGH/IHA palliative care teams.

They have some cultural and legal issues here with respect to the use of narcotics for pain control. Not only do the have no palliative care programmes for the painful dying, they use virtually no analgesics for post surgical pain management. Physicians and nurses are concerned about being charged with narcotic abuse and consequently narcotics aren't used.

There are high levels of support for this culture to change, both within the MoH and with some key physicians.

We will help Donald to design his palliative care plans. He will embed it within their culture and then we will help him develop some regional pilot implementation programme.

This model could become a Zambian policy.

Also, there is the issue of supporting the appropriate use of analgesia following surgery.

Yet another success that this MoU will be the placement of Jessica and Lianne in Mongu where they will be involved in the teaching of the 2 year nursing diploma course. They start in Zambia this June. We need to get them some financial support. No, we will get them some support. This is a very important activity since it is our entry to rural Zambia where the needs are high.

Finally, this MoU will be essential for planning other ideas, some of which are in preliminary mode.

More later. Bill

Whither Mongu?

by Bill Nelem
April 2008


The road to Mongu, heading 600 kms due west from Lusaka, is characterized by two unusual features.

First, on the Zambian scale of pot-holed roads of 1 to 10, it scores a low 1, very few potholes. Most unusual, and almost for sure, this road has 'worn well' because it lacks the heavy transport truck traffic that has ruined the Great North Road that links Livingston to Lusaka and the Copperbelt. As one drives this remarkable road, another reality emerges from the subconscious mind. If this road is so well preserved, it's lack of traffic portends that perhaps the destination of Mongu is 'far from the beaten path', so to speak. Isolated, one might surmise. No great tourist Mecca this. Don't expect any 5 star hotels at the end of this road.

The second unusual feature of this road is that it is so 'Germanic', so un-British.

Roads built in Africa in the German colonies such as Namibia or

Tanzania, for example, runs in absolute straight lines for hundreds upon hundreds of kilometres. This is unlike those built in British colonies where the roads simply meander haphazardly back and forth, modelled as if they looked like the curvy unplanned back roads of south London. Here you have a road to Mongu in a former British colony that must have been built by German sub contractors!

Along the road I pass clusters of children and I wave. Enthusiastically, they wave back.

A woman squats at the roadside to void, breast-feeding a contented infant. Strapped to her back, a second infant screams uncontrollably, impatient for his or her turn at the breast.

A man wears a rugby jersey with the number 13 on the back. Above the number, incongruously, is embroidered the name 'Smith'.

Two boys push toy wheel barrows made out of wire coat hangars.

I pass mud houses with crudely thatched roofs. Eight-foot high corn crops grow, planted besides villages. Nourished by this year's heavy rains they bear healthy cobs of corn that will be needed during the dry season that follows.

A diesel truck spews out clouds of black smoke, completely oblivious of its impact on global warming.

Sticks of sugar cane, bananas, mangos and live chicken are for sale at the roadside.

Some ride bicycles, some ride tandem on the back of bikes, but most of the people walk.

A young man proudly holds the only motorcycle seen today, surrounded by a crowd of admiring and envious bystanders. In turn they respectfully touch the orange painted beauty.

A bus is stopped at the roadside, broken down, no doubt. The passengers stand aimlessly by waiting for something to happen. Who knows how long they will wait.

More ominous is the fully loaded freight truck, also stopped at the roadside. There is air in the tyres, but the crankshaft has been removed. Forlorn and forsaken, it lies on the ground alongside the stranded truck. Now this is a major problem.

The road to Mongu passes through the Kafue National Game Reserve.

Clusters of monkeys and baboons scurry into the long side grass to avoid the car. Vultures scavenge on a road-killed jackal. Impala stand in herds at the roadside, furtive and pensive. Their lives depend, literally, on their instinct to bolt on a nano-seconds' notice.

A tree pushed over by an elephant covers one of the road's two lanes.

Like giant pancakes, elephant dung litters the road. With all of this elephant activity, one senses that a large body of water nears, recognising the elephants' proclivity to bathe in water during the heat of each day.

Sure enough, over the next hillock lies the Kafue River. It is a large river, it's water moving slowly, tranquil.

At the river's edge, aware of lurking crocodiles, women cautiously wash clothing.

On leaving the reserve, I'm stopped at a checkpoint. The guard advises that a sister needs a ride to the next village. Now a sister's need is a request to heed. For the next ten minutes my front seat passenger sits motionless, respectful, silent.

Perhaps I was a bit hasty in suggesting that there may not be good accommodation to be found in Mongu.

Arriving in town, I notice the 'Cross Roads Lodge - good accommodation'.

Aptly, it's located near the cross roads between the road to Senanga and the road to Lusaka. Nearby are the Mongu General Butcher and Mini Mart.

What more could anyone want?

Next I see a sign for the 'Majesty's Lodge - Best luxury rooms – where guests have the opportunity to relax in peaceful surroundings'. Well, that says it all. Who could argue with that?

I'll make sure that Joe knows about this one when he sends people to Mongu.

At noon I approach a sign that says 'Mandanga guesthouse - accommodation - restaurant - bar'. Aah, a good spot for lunch. I pull into the drive to find the front door and the windows boarded.

I settle on the 'Cheshire Home for Physically Challenged Children' run by the Presentation Sisters. Rosemary put me onto them. I'm greeted at the door by Sister Cathy, she of Irish accent. I'm given a warm handshake and a key to my room. There's no need for registration or for any payment. 'Come and go as you please', I'm told, but they insist that I join them for meals.

This is where Jessica and Lianne will stay when they teach at the nursing school. It's spartan, clean and safe. It's perfect! There is no way that they will be staying at the nurses’ hostel adjacent to the nursing school where none of the above parameters hold.

Gene will be pleased to know that the disabled children at the home all have mosquito nets. The Sisters say that there has been widespread distribution of nets in Mongu. They've even had an insecticide re-impregnation programme for older nets. The biggest problem now that all have been given nets is that of compliance failure. The nets do make the hot nights hotter.

I don't have time to go to Senanga, but I drive south along the Zambezi flood plain for a short distance. The road has a Zambian pothole score of about 7 or 8!

For kilometre after kilometre along the road to Mongu, I see telephone posts loyally suspending three flimsy wires, presumably the power source for all of western Zambia. Yes, there is electricity in Mongu, but how effective is their communication network?

Waiting for dinner and holding a glass of wine offered by one of the

Sisters, I startle when my Blackberry phone rings. Unaware that I'm in Zambia, a friend in Kelowna dials my local cell phone number just to chat. Here I am in Mongu and the call comes in loud and clear.

I send myself a test e-mail message on my Blackberry. Within three minutes the message returns!! Now that is impressive. I wasn't able to do this in Beirut.

I later learn that Mongu is on the satellite telecommunication network grid linking Africa north to south.

Here's another pointer for Jessica and Lianne. When they go to Mongu, they will take with them a trusty Canadian Blackberry. This way they will be in constant communication by both phone and e-mail without needing access to an Internet source. Even here in Mongu, the Blackberry does it all!

The hospital is basic but remarkably functional. Two operating theatres have been recently refurbished. Despite the presence of 11 doctors and 108 nurses, they are severely manpower depleted. They are constantly short on medications and dressings. Out of oxygen last week, they 'borrowed' the last remaining O2 cylinder that they try to keep on hand at Cheshire Home. They don't expect that it will be returned or replaced. The Health Partners Canada supply kits will be most helpful here - so too would oxygen concentrators.

Always looking for the opportunity and not the problem, I see that this place has significant unused capacity, potential for third world development initiatives - think fistula programmes, community surgery, circumcision, prevention plans, palliative care etc. This site is typical of at least a dozen other regional community hospitals scattered around Zambia, all offering the same opportunities. The need is overwhelming.

I spend two hours at the school of nursing, and I come away with two impressions. First, they are very dedicated to doing the best they can, and second, this place will never be the same after Jessica and Lianne have come and gone. The Principal, one of the teachers, is away today and so I will have to return before I leave to set up the details for Jessica and Lianne (JL). Alfred Mandona's absence allows me to spend time with the other two teachers, Pelena Phiri (she wants to do a Master's- I suggested UBCO) and Mumbuwa Silumba, a fine young man. They will welcome with open arms two Canadian sisters (!) to their teaching ranks. They are short of teachers. They also have 4 clinical instructors. They have a two-year diploma course, graduating about 45 per year. School year starts first semester July - December, 2nd term January - June.

'What are your needs?' I ask.

Curriculum development - Action Jessica and Lianne

Library completely outdated - Action Jessica and Lianne (JL)

Teaching aids almost non-existent - Action JL

As I said, this place will never look the same once JL strike!! It's a great opportunity that awaits them.

Leaving Mongu for Lusaka, I'm stopped again by the same guard at the entry to the game reserve. On this occasion, I see no silent sisters standing still. The guard's request; 'Please take a carton of fish to the market in Lusaka'. I look down and next to him I see four fly-swarmed cartons of smelly fish rotting in the noonday sun. From the cartons ooze rivulets of clotted blood and slime that mingles with the red rusty African sand transforming the mixture into a yellow – green slag. Much to the guard’s dismay and disappointment, I decline the request!


I’ll write again soon. Bill

Instructions for Bill

by Bill Nelem
April 2008

I sleep fitfully awakening with the airplane travel map advising that we are11,000 m over Reykjavik, - next stop London and then Lusaka. Whilst most of the passengers sleep, some nighthawks the likes Rachel and Rebeccah watch movies on their seat back screens.A Chinese woman seated besides me eats her now cold vegetarian supper. The stewardess brings me a small bottle of red wine - a French Pinot Noir, no less. Paul will be impressed!

I'm alert now.I focus on my many instructions.
Jessica and Lianne, two recent UBCO nursing grads will spend several months teaching and working at the community nursing school in Mongu:
My instructions: Go to Mongu and find some answers;
Accommodation, where will we stay? The work, what's it all about?
-What options are available?
-How much this would cost?
-How close is it to the teaching college?
-Are there cooking facilities?
Nursing Curriculum
-How long are the semesters?
-When do the semesters start?
-What teaching equipment do they already have?
-What teaching equipment/supplies can we bring?
-What areas do they want us to teach?
Local Hospital/Clinic
-What medical supplies are needed?
-Opportunities for us to work there?

Viktor Frankl, were he alive, would like Jessica and Lianne! I will tell them that Viktor Frankl's 'Man's Search for Meaning' is a required reading assignment!In Mongu, I'll meet Mr Mandona - the Principal at the School of Nursing. I will also meet Pelina Chibanje and Silumbu Mumbuwa, Instructors at the nursing office. I likely won't make it to Senanga.

Then there's Rosemary, born in Lusaka now residing in Kelowna – and her instructions:

Find Susu, Rosemary's old cook. Make sure that he has a bicycle. If he's dead, find his wife. If she's dead too, then find Alison, their son.

He's a responsible sort, and make sure he has a bicycle. He lives at Erwin's farm, part of the property that once belonged to Rosemary's family. The property is on Leopard's Hill Road, past Woodlands. Should be an easy find!!

John and Jane Jellis, he a partly retired surgeon, live on 'Border', the other part of the farm. This property is now a bird sanctuary. For your memories Rosemary, I will enjoy my visits.

Gene's list of instructions is quite detailed:
Start with Laurie Rogers at the Canadian High Commission to update her on our progress. I always start my visits in Zambia with my friend and former medical school classmate, Chifumbe Chintu, the Paediatrician - the Professor!!

Next, get Margaret's airline ticket and her signed letter of invitation to her ASAP. She needs to get her Canadian visa pronto. Dr Margaret Maimbolwa is the Vice Dean of Medicine, Director of the University of Zambia (UNZA) Nursing School. Margaret returns to Kelowna with me in April to spend 3 weeks with UBCO Nursing planning 7 or 8 different collaborative projects.

The Vice Chancellor at UNZA, Stephen Simukanga, a mining engineer, is to be a signatory on our UBCO - UNZA Memorandum of Understanding with respect to all matters of health collaboration. He is a must. He always answers his cell phone directly. Like our DVC, so does Doug Owram!! The other co-signatory on the agreement is Dean of Medicine Yakub Mulla.

We have a telephone meeting with UBCO and UNZA Friday this week to conclude the signing of the document. If you can make the meeting Doug, it will be appreciated, Joan's office 7 am March 14. I'll be with the Dean and the VC in Lusaka 5pm Zambian time.

Also at UNZA, I will meet Dr Wilson Mwenya the DVC; Kenneth Chanda, Librarian, and Prof Richard Siaciwena, Distance Education Directorate.

At the University Teaching Hospital, besides Chifumbe and Deans Maimbolwa and Mulla, I will meet the surgeons, the oncologists at the Cancer Clinic, Donald Kalolo, Chief Pharmacist, Gavin Silwamba, Community Medicine, Dr Stewart Reid, a Canadian friend, Internist also works at UTS. Chipefwe Sichilima is in charge of E Learning. I'll brief him on our tele-medicine in Kelowna.

Then I must meet with Emily, Norman and Lumba at 'Women for Change'.

Henry Lyatumba is my Rotary Lusinta contact, and I will find Christopher Simoonga at the Ministry of Health.

Can you believe it? The Chinese lady beside me on the plane is snoring, and the nighthawks have nodded off!! Maybe I'll sleep too.

Better health in Zambia

by Bill Nelems

This is a story that will forever remain incomplete. How can that be?

The journey begins for the enhancement of medical and nursing education in sub-Saharan Africa, beginning in Zambia. The scope is so comprehensive that the real journey will go on forever. The need is overwhelming.

Imagine if you can that you are sitting in a crowded space. Fifty percent of the people around you are afflicted with HIV/AIDS, Malaria or Tuberculosis, the infectious trilogy that cripples most of Africa. Their collective life expectancy will be measured in months if medicines and care do not arrive in time. Now, how are you feeling, and what are you thinking about?

And what else in the way of medical care exists for the so-called 'non-infectious' diseases such as hypertension, diabetes, basic surgical care for trauma, obstetrical and neonatal care, and so on, you might ask? Precious little is the answer.

Fortunately, at last some monies are flowing to stem the infectious trilogy. Thanks to CIDRZ, the Clinton Foundation, the Gates Foundation and others significant players, help is on the way.

A clipping form the CIDRZ website reads:

How can the tide be turned in the battle against HIV/AIDS and other infectious diseases in Africa? For the team of doctors, researchers and health care practitioners at the Center for Infectious Disease Research in Zambia (CIDRZ), the answer is clear. A three-pronged approach brings both short and long term solutions.

Clinical Care is given to patients, using the highest quality services and practices;
Research is conducted using international standards, but always informed by local practice;
Training is ongoing, increasing the level of knowledge and understanding of both African and expatriate doctors, as well as researchers and health workers.
But what, we ask is happening beneath this mantle of infection?
When traveling through Zambia, especially to rural areas, we notice a desperate lack of basic access to the services and supplies that we so take for granted in first world countries.

We have begun our work in Western Province, at the request of significant stakeholders in Zambia. Most notably, it has been Dr Margaret Maimbolwa, Assistant Dean of the School of Medicine who has urged us to this province.

Our University of British Columbia - Okanagan has signed a 'Memorandum of Understanding' with the University of Zambia to collaborate on all matters relating to health.

With this MoU, our Nursing Faculty will begin to work with their Zambian counterparts on matters such as curriculm development, faculty education and access to world standard teaching simulators for all their students in Lusaka the capital city.

But from there, our major efforts will be to develop a 'Non-Infectious' disease curriculum in a multi-disciplinary fashion, nurses, physicians and other health professionals working together. Where possible we will link with other funded Non Governmental organizations (NGOs), and where new ground needs to be broken we will fundraise separately and write grants to funding agencies.

To date we have developed a successful linkage to the Canadian Network for International Surgery. Several of our members are now Certified Trainers for CNIS and we ran our first Essential Surgical Skills training in Mongu Western Zambia in October 2009. Our nurses developed parallel and complementary nursing skills modules. Next our family physicians will develop the peri-operative modules and then a comprehensive non-infectious curriculum. Support for these initiatives from Zambian partners is overwhelming. We also receive counsel and advise from the Canadian Coalition for Global Health Research.

Already plans are developing for a potential national Zambia programme to commence in 3 years time based on our pilot experiences in Western Province.

"You came all the way from Canada just to do this evaluation in Kalabo?" asks Justine – Operating Theatre Nurse

"These teachings must be important."

Education Programmes forNurses, Clinical Officers, Medical Licentiates and Physicians in Western Province, Zambia - 2011

by Bill Nelems

It's July, and we're 3 months into the dry season. The floodplains and lakes are shrinking. The herbivores are congregating near the large rivers, now significantly below their high-water levels. The animals compete for both moisture and for food. These are good times for the carnivores, their prey all neatly compressed next to one another.

For us, this trip is like no other. We've come to Western Province Zambia this time to formally evaluate the effectiveness of the teachings that we've offered to health care workers who staff some of the most remote clinical units on the planet.

During the last three years two of our nurses taught at the rural nursing school for six months. A science grad, now a medical student in Australia spent time retro-fitting and making operational old computers at the same nursing school. Canadian nurses, family physicians, surgeons, and an anaesthesologist have taught the nursing and medical aspects of 40 different essential surgical skills, techniques of inguinal hernia repair, hypertension, diabetes, intensive care monitoring and life support systems. We've also sent two annual iterations of our UBC Okanagan nursing students to Mongu, replete with professorial and teaching staff. Apart from the education of the students at the nursing school and the impact of our nursing students, we've also taught 90 nurses, midwives, clinical officers, medical licentiates and physicians.

And now for the fun part of tracking them down at their front line working sites to find out if these teachings are having any impact on improved patient care, improved outcomes and more job satisfaction for the worker.

Cameron J, at the ripe old age of 23, seems like an improbable leader of this evaluation team, and yet the universe has seen stranger things happen before! In fact, he's the perfect person for the job. He's the right person for the right job at the right time. Under the veneer of his youth lurks a remarkably mature and compassionate human being. Now a member of the first graduating class from Quest University he brings with him the eclecticism that is unique to that new and remarkable institution of higher learning. As a third year student at Quest, he came to Zambia with one of our essential surgical skills teams and performed an in depth evaluation of that course. With the support of his university mentor, he cut his first set of teeth in the art of international development evaluation.

Then, as the planning for this evaluation trip began, he spotted the opportunity of his young life-time, reaching up like a receiver waiting in the end zone to catch the 'Hail Mary' pass.

Cameron J was ready and the pass was perfect. You'll have to wait until the final evaluation report is published to find out if he caught the ball or if he fumbled the play. You may get a clue as to the outcome if you listen carefully for the roar of the crowd!

Lianne, who has already cut her 'ten thousand hours' teaching in Zambia is back with the team to evaluate physicians, nurses, clinical officers, medical licentiates and midwives. This is her sixth trip to Zambia. She first became infected with the 'Africa bug' when, as a nursing undergraduate student, she went to Ghana with Mamma Fay as her professor / mentor.

It was Lianne, along with Jessica, who went to teach for six months at the nursing school in Mongu, Western Province.

It was Lianne, along with Jessica, who returned to Zambia to teach our UBCO nursing students along with Fay, now leader of student teaching in Zambia.

It was Lianne, along with Jessica, who rode the Tour d'Afrique with Bill to raise money for the Okanagan Zambia Health Initiative.

And so, it's only appropriate that Lianne should be a member of this evaluation team. At the age of 26, she fits the job like a fist fits the glove, another trump card for youth, passion and vigour!

The third member of the evaluation team is Dr Andrew Silumesii, CEO of the Lewanika General Hospital in Mongu, capital village of Western Province. Andrew can only be described in superlatives. Without his help and support, OkaZHI could have achieved nothing - absolutely nothing! It was Andrew who supported our teaching efforts at the nursing school. It was Andrew who supported all of our teaching programmes. It was Andrew who supported Fay and her UBCO nursing students. It is Andrew who encouraged us to undertake this evaluation effort. A husband, and a father of two young boys, Andrew is the very model of commitment and passion for the health of his fellow Western Province citizens. He understands the needs of his people like no one else. We are honoured that he would join the team.

The fourth member of the team is Bill - whilst the founder of OkaZHIhttp://www.okazhi.org, he sees himself mainly in the role of cheerleader and the writer of blogs. Noted, it was Bill who actually threw the 'Hail Mary' pass to Cameron J, 49 years his junior!

Preparation for this evaluation trip was intense.

Key to the groundwork was having daughter Rebeccah as counsellor and advisor. Rebeccah is a senior international development evaluator. Now an independent consultant, she has experience with CIDA, IDRC and with several other NGO's. She is personally modest about her achievements, but father Bill has huge 'bragging rights' as to her successes.

Working with 'Rebeccah's grid' for international evaluation, modified specifically for Zambia, Cameron J went to work, logging dozens of hours fleshing out questionnaires and interview formats to match the grid. With input from all key OkaZHI members, and an application to UBC human behavioural ethics department, Cameron J entered the end zone, nervously awaiting the ball now lofted high into the sky.

Lianne, for her part, was able to list all of our students, their locations and their contact numbers. With her uncanny sense of context and her knack for social networking, she coordinated our logistics like no other.

Andrew, with his Ministry of Health 4x4 vehicle and his driver Mr Mulambo, was to become our ‘eyes and ears’ on the ground. His commitment to the success of this venture was absolute.

On arrival in Lusaka, Cameron and Lianne explain our mission to Dr. Joseph Kasonde of ZAMFOHR. He is supportive and offers helpful advice.

The team is united at Cheshire Home in Kaoma when Andrew drives 2 hours from Mongu, and when Lianne, Cameron J and Bill travel 6 hours from Lusaka aboard the Shalom bus, listening alternately to sermons interspersed with the beat of Zambian music.

There is more drama in our meeting here than meets the eye. We find ourselves at the Cheshire Home orphanage in Kaoma.

“Isn't that the orphanage where 'Lianne's baby' was sent?”

In October 2008, when Jessica and Lianne were teaching at the nursing school in Mongu, a premature baby girl was born. The mother suffered a placental abruption, and bled to death. The baby, at 28 weeks gestation, and weighing only 900 grams, was left to die - the mortality for this degree of prematurity being overwhelmingly high. The chances of survival for a baby like this admitted to a Canadian neonatal unit would be about 50% - in rural Zambia, that this infant might survive is unimaginable!

After 24 hours without feeds, Lianne and Jessica appeared, initiating a round the clock vigil, adding frequent feeds with infant formula. A month later, Fay, Gary and I - visiting in Mongu - saw and photographed the baby, then about 1 kilogram in weight.

Now three years later, and recognizing the poignancy of the moment, camera ready, I followed Lianne to the orphanage in Kaoma.

Then it happened. Tears welled in Lianne's eyes as the baby was brought to her - perfectly healthy - still asleep from an afternoon nap.

Talking about evaluation, this child is a miracle as measured by the only criterion that really matters; a live and healthy child.

Mwewa was our first candidate for evaluation. If the world had a few more Mwewa's, we would surely live in more harmony. A physician extraordinaire, it was such a delight to see him again. He attended two of our courses.

Driving north to Lukulu, we saw the newly acquired Chinese mobile hospital deployed for the first time in Western Province. The current expectations are that these units will flounder - but that's a topic for another day, and a challenge for another evaluation team!

Returning to base at Sister Christina's in Mongu, we had nabbed 7 completed evaluation interviews with attached questionnaires, and we had visited two of our intended 8 villages. The team's confidence was soaring.

Mongu - home to 55 health care workers that attended our various and sundry courses - was a state of controlled madness as we tracked down most of them for their participation in our evaluation process. Two things stood out - the willingness of all to participate, and the frankness of their responses - ideal conditions for a successful evaluation outcome.

As is our usual custom, we met with Dr Sitali, the Chief Medical officer for Western Province and the Permanent Secretary - think Premier.

And then, no visit here could be complete without meeting with SK - Silumelume Kufunduka Mulambwe - retired Zambian diplomat and direct descendant of the first Barotse king.

Notable were interviews with Drs Liywali, Idi, Kamanda, Kongola, Kazuma, and with Precious, Lillian, Mumbuwa, and Pelini.

And now, we're off to Kalabo on the far side of the Zambezi floodplain.

Much as I love Mongu and all of the people there, Kalabo is one of my favourite spots. Home to our students Frederick, Arthur, Patson, Willard and Justine, and to the District Medical Officer, Douglas Shingini, there is a spirit of adventure and courage that I find hard to describe.

It's not the most remote village that I've ever visited. That distinction goes to Tuktoyuktuk, but it ranks a close second. Here they don't suffer the extremes of cold seen in the western arctic, nor do they see a season completely devoid of plant life and agriculture. Here they grow rice in the low waters of the floodplain and maize at the peak of the rainy season, also enjoying a continual supply of fish from the rivers. What makes life here more difficult, and unlike Tuktoyuktuk, is the lack of infrastructure and access.

Tuk has an electronic radiology service. Kalabo struggles with basic x-rays, that is, when the power system is up. Tuk has an all-weather 24/7 air medivac system. Kalabo has an airstrip, but no aircraft or ambulance support for patients.

Even with the high waters receding now, we were still able to travel the 74 kms across the Zambezi by boat through deep channel trenches.

We're heading south now to Senanga, Sioma, Shesheki and Sishili as our destinations. That will bring us to the Caprivi strip border with Namibia, and Livingston as our nearest major town.

At the trip’s end we had made contact with 74 of the 90 professionals we taught – all working at their remote sites of employ.

All in all, we gathered an enormous amount of data.

Even though the final report has yet to be written, you know that Cameron J caught the ball in the end zone because of the roaring of the crowd.

Yes, they all found the teachings to be most helpful.

Some quick snippets:

(Remember that some of our students had only 10 days of training as opposed to a 5 year residency training in a first world country!)

“Our wound infection rates are down.”

“I’ve been able to do bowel anastamoses.”

“I’ve done 60 inguinal hernias since you taught us.”

“I placed a chest tube in a two year old with empyema – and she survived.”

“I’ve done three leg amputations.”

“I’ve done a splenectomy for Sickle Cell disease.”

“Doing Caesarean sections is easier now.”

“I feel more confident.”

“We used your templates to start our Hypertension and Diabetes clinics.”

Building the Capacity of Health Care Professionals in Western Province, Zambia

An Okanagan Zambia Health Initiative (OkaZHI) Evaluation Report
Building the Capacity of Health Care Professionals in Western Province, Zambia - An Okanagan Zambia Health Initiative (OkaZHI) Evaluation Report

Cameron Jones, Andrew Silumesii, Lianne Jones, Rebeccah Nelems and Bill Nelems - January 2012

Executive Summary

www.okazhi.org

In 2006, Dr. Bill Nelems made his first trip back to Zambia in over 50 years to meet with his colleague and medical school classmate Professor Chifumbe Chintu. During this visit, Professor Chintu introduced Dr. Nelems to a range of key players in the Zambian medical and health sector to discuss potential international cooperation.

Years later, a series of Canadian-Zambian collaborations have taken place, building on this initial visit:

· Institutional and personal relationships have been established between Zambian and Canadian colleagues and institutions, with the shared vision of promoting and improving health outcomes and quality of care in Zambia;

· A Canadian registered charity, the Okanagan-Zambia Health Initiative (OkaZHI) was founded in 2010, under the auspices of which numerous Canadian health professionals (doctors, nurses, healthcare educators, etc) have joined Nelems in the commitment to improve health care in Zambia;

· The University of British Columbia Okanagan (UBCO) established a Memorandum of Understanding (MOU) for collaboration with the University of Zambia (UNZA);

· OkaZHI is in the process of signing a formal MOU with UBCO since many members are affiliated with both institutions and share common interests in Zambia;

· OkaZHI built a collaborative relationship with the Canadian Network of International Surgery (CNIS – an international NGO committed to sharing knowledge, expertise and experience to promote lasting and sustainable improvements in health and safety in the developing world), with whom it collaborated to deliver two adapted CNIS training modules in Western Province, Zambia;

· OkaZHI developed and delivered an additional four medical training courses and matching nursing courses in Western Province, with the guidance and support of the Zambia Ministry of Health and the Lewanika General Hospital (LGH);

· Between 2009 and 2011, 92 Zambian health professionals from Western Province attended OkaZHI training courses (53 nurses, 25 physicians, 5 medical licentiates, 9 clinical officers);

· UBCO established an annual nursing practicum, under which 45 UBCO 4th year nursing students have traveled to Mongu, Western Province to work for an eight-week period since its establishment in 2010; and

· OkaZHI-UBCO established linkages with other Canadian players working in Zambia, recently becoming a member of the “Zambia-Canada Research Partnership” facilitated by the Canadian Coalition for Global Health Research (CCGHR - a knowledge and relationship broker committed to reducing health inequities through the production and use of knowledge), with a goal of ensuring coordination and harmonization of Canadian efforts in Zambia.

Five years after Dr. Nelems’ and Professor Chintu’s initial visit, it was time to take stock. In July of 2011, an OkaZHI evaluation team travelled to Western Province, Zambia, to formally and systematically assess contributions of, and challenges to, OkaZHI’s efforts since its inception – seeking Zambian colleagues and partners’ experiences, perspectives and suggestions for OkaZHI as it moves forward.

OkaZHI Executive Director Bill Nelems and Canadian OkaZHI members Lianne Jones, Cameron Jones teamed up with Dr. Andrew Silumesii, the Medical Superintendant for Lewanika General Hospital, Mongu, Western Province, in order to conduct a thorough, qualitative evaluation of OkaZHI. A comprehensive evaluation framework with methodologies was developed and received UBC’s ethics approval. Evaluation methodologies included a detailed, anonymous written survey completed by 72 OkaZHI course participants, site visits and one-on-one interviews with 70 OkaZHI course participants. Interviews with 7 other key stakeholders in Lusaka and Western Province were also held.

The data gave evidence to eight key findings. Detailed in the report below, these include:

Finding 1: Zambian course participants reported improved health outcomes for patients, due to improvements in their delivery and quality of care following the OkaZHI courses.


Finding 2: Zambian course participants said they felt more confident in their practice because of the new skills and knowledge they had acquired through their collaboration with OkaZHI.


Finding 3: Course participants found OkaZHI courses to be highly relevant to health care needs in Western province and directly applicable in their day-to-day work.

Finding 4: Course participants found OkaZHI courses, methodologies and instructors to be highly comprehensive, professional and innovative – though courses were commonly critiqued as being too short.


Finding 5: 90% of OkaZHI course participants said they have shared knowledge gained in the courses with colleagues, suggesting OkaZHI is having reach beyond the classroom.


Finding 6: Course participants health professionals noted less than expected use of eGranary digital library due to lack of training and accessibility.


Finding 7: Course participants identified a variety of contextual factors, which affect the overall impact of OkaZHI`s interventions, including workload issues, retention issues and lack of equipment.


Finding 8: Course participants made a number of specific requests about directions for ongoing support from OkaZHI, including teaching at UNZA School of Medicine.

Amidst these findings, three key lessons emerged.

First and foremost, OkaZHI efforts would not have achieved anything were it not for the incredible commitment, partnership and guidance of its Zambian colleagues and partners.

From Dr. Margaret Maimbolwa, Assistant Dean of the University of Zambia School of Medicine, to Dr. Sitali, the Provincial Medical Officer for Western Province, to Dr. Andrew Silumesii, the Medical Superintendant for Lewanika General Hospital in Mongu, OkaZHI has been fortunate to have the highest level of commitment, support and partnership from key Zambian actors and institutions. This has enabled OkaZHI’s work to be guided by locally identified priorities and situated within existing institutions and initiatives on the ground.

The time invested by OkaZHI members on the ground in Lusaka and in Western Province in the past several years has helped to enrich these relationships – with the majority of interviewees commenting, without solicitation, on the high degree of trust, partnership and collaboration they have experienced in their interactions with OkaZHI personnel. This sense of true partnership and collaboration is a defining feature of OkaZHI’s approach and a key contributing factor to its successes to date.

OkaZHI has also been effective at establishing linkages with other Canadian actors working in both the sector – such as the Canadian Network for International Surgery (CNIS) – and in Zambia, through the CCGHR-facilitated “Zambia-Canada Research Partnership”. Ensuring coordination and collaboration with Zambian, Canadian and other international actors working in the sector in Zambia will continue to be critical to OkaZHI’s successes.

Second, OkaZHI efforts to date have yielded significant outcomes in Western Province – especially given the relatively short timeframe in which it has been working in Zambia.

97.2% (70 of 72) of Zambian health professionals surveyed and interviewed reported improved health outcomes for patients, due to improvements in their delivery and quality of care following the OkaZHI courses. Every doctor provided examples of decreased or eliminated post-op infections, complications, and declines in patient referrals – the latter being most significant for rural medical staff operating out of remote districts. Doctors, nurses and medical licentiates all reported a decrease in duration of patient stay, due to reduced post-operative infections, stating that this has increased the number of patients addressed daily. Further, 95.8% (68 of 71) of survey respondents reported an increased confidence in their clinical skills following OkaZHI programming. Improved speed, reduced infections and/or mistakes and decreased patient referrals were commonly cited as direct outcomes of an enhanced confidence gained through OkaZHI trainings.

OkaZHI courses were largely regarded as relevant to local health needs. 100% (72 of 72) of participants claimed to have used learned skills in their day-to-day work – and 90% (63 of 72) reported having shared material or knowledge learned with colleagues who did not attend the courses.

This data points to a clear mandate for OkaZHI to continue building on its successes. Interviewees and survey respondents were unanimously positive about their desire for OkaZHI to continue working in Western Province, making a series of commonly expressed recommendations or requests. The recommendations varied widely but several requests were frequently repeated without any prompting. 93% (66 of 71) of participants surveyed requested “further training or support” in at least some aspect oftrainings previously received from OkaZHI. Other frequently identified requests pertained to how OkaZHI could amplify its presence and support for healthcare practitioners in Western Province.

The third key lesson that emerged in the evaluation process is that there are a number of external factors that pose challenges to OkaZHI’s efforts, including the long-term sustainability of its successes. 

Throughout the evaluation, Zambian colleagues identified a range of factors inhibiting the effectiveness of OkaZHI’s efforts in the region. For the most part, these issues are well beyond the scope of OkaZHI’s work, such as the lack of equipment, workload issues and the retention of human resources for health in Western province. To the extent that it is possible, however, it will be incumbent upon OkaZHI to not only be aware of these challenges, but to find ways to mitigate these challenges with its Zambian partners, thereby maximizing OkaZHI’s contributions:

· While OkaZHI is not able to reduce the workload burden experienced by so many health professionals in Western Province, OkaZHI must continue to take this burden into account in the design and delivery of all courses;

· While OkaZHI does not have the mandate to supply or provide equipment, the lack of technical knowledge for how to use existing and unused equipment also places constraints on local health care workers’ capacity to use their knowledge and skills. Supporting the training of equipment technicians in the use and maintenance of existing medical equipment (ECG, incubators, Defibrillators, Ventilators) – while it does not resolve all of the equipment challenges – could contribute to the reduction of equipment-related constraints;

· The poor retention of human resources perhaps poses the most significant challenge to the long-term sustainability of results to which OkaZHI contributes within Western Province. While OkaZHI may be contributing to the enhanced capacity of Zambian health professionals, who will take this capacity wherever they may go, this finding suggests that its contributions to improved health outcomes, quality and delivery of care in Western Province are ultimately less sustainable. OkaZHI needs to develop some mitigation strategies to secure greater long-term sustainability of its efforts. One such strategy could be drawn from the recommendations made frequently by Zambian colleagues over the course of this evaluation process – namely, the establishment of a ‘Train the Trainers’ program within Western Province. This would support greater local ownership of OkaZHI’s work with a view to the potential eventual devolution of major components of the OkaZHI program. The ‘Train the Trainers’ program was identified by a range of interviewees as a way to support continuing medical education, while also building greater responsibility and collaboration between Canadian and Zambian practitioners. As such, OkaZHI training could be embedded within local institutions, building institutional capacities, instead of focusing on building capacities at the individual level alone. Other strategies could be developed as part of a sustainability strategy, focused on building institutional-level capacities as a way to complement the individual training delivered by OkaZHI.

If OkaZHI is to benefit from this evaluation process, the evaluation team urges it to take the above factors into account in future planning and programming.

Final points for consideration, detailed below in the report, include the following:

1. Given the numerous factors that pose significant challenges to the long-term sustainability of OkaZHI’s efforts in Western Province, OkaZHI could consider developing a sustainability strategy that mitigates these factors (e.g. development of institutional capacity).

2. OkaZHI could establish a policy for how it will review and/or respond to requests for the provision of physical equipment to Zambia.

3. OkaZHI could ensure that each of its courses leaves ‘hard copy’ educational resources behind for medical staff in Western Province.

4. The regular testing of skills retention amongst OkaZHI course participants could support the systematic monitoring of OkaZHI contributions and its sustainability.

5. The course participant identification process could be reviewed in conjunction with Zambian colleagues to ensure maximal relevance of course material to the participants.

6. OkaZHI could consider integrating communications and administration skills into their program of courses.

7. OkaZHI’s evaluation and planning efforts could benefit through further collaboration with the Zambia Ministry of Health, with respect to accessing existing health information data for Western Province, Zambia.

8. OkaZHI could consider expanding into teaching about certain ‘silent’ conditions.

9. OkaZHI could continue to enhance its impact and effectiveness by strategically building on identified opportunities to collaborate with other Canadian and Zambian based NGOs and Universities.

In conclusion, this evaluation found that OkaZHI, in partnership with its Zambian and Canadian colleagues, has contributed to significant outcomes in Western Province. Through cooperation and support from OkaZHI, Zambian health professionals working in Western Province have reported being able to offer to their patients better quality of care, reduced referrals, reduced infections, reduced hospital stays, better long-term prognoses, and decreased mortality rates. Based on the input of Zambianparticipants and stakeholders, OkaZHI has a clear mandate to continue building on these successes in the coming months and years. As done in the past, this programming will need to be developed in close partnership with Zambian colleagues – as well as Canadian colleagues working in Zambia – to ensure its relevance, effectiveness, sustainability and ultimate impact in terms of improving health outcomes and quality of care in Western Province, Zambia.

© All Rights Reserved Okanagan Zambia Health Initiative 2008-2011

Needed - A Rural Oxgenator in Zambia

by Bill Nelems

Twenty percent oxygen everywhere, yet hardly an additional molecule to spare!

Professor Jellis is coming from Lusaka to provide his two-monthy Orthopaedic surgical care for the physically challenged children at Cheshire Home in Mongu, Western Zambia. Over a two day span more than 30 patients will require oxygen in support of their general anaesthesics at the Lewanika General Hospital.

The pre-operative ward is bustling as Ronny, one of the OR theatre nurses prepares the children for surgery. He is assisted by Leah, Alex, Gabby and Kelsey, student nurses from University of British Columbia - Okanagan. The operating room theatre, resplendent with anaesthetists and nurses, is ready to roll. Prof Jellis works fast and insists on a rapid flow through of patients, not always the case here.

Four oxygen cylinders stand at the entrance to theatre. Two are empty, two are 'filled' with oxygen, although the pressures have not been measured to determine the adequacy of fill. To achieve this modest oxygen supply for the Orthopaedic patients, elective surgery had been cancelled for a week prior, and none was available for the ICU now made functional by OkaZHI's Kim East with her teaching of November 2010.The last 3 of 30 patients go to surgery after the oxygen has been exhausted.

The delivery trucks normally used to bring oxygen cylinders from Lusaka, 600 kilometres to the east, stand idle. There will be no oxygen available for next week. The challenges in delivering health care to this rural part of Africa are myriad, but the lack of an adequate oxygen supply conjures up the metaphor of a system suffocating in more ways than one.

The Lewanika General Hospital serves as the referral centre for all of Western Province. An urgent and sustainable solution must be found - now. The lives of hundreds of patients, and over time, thousands more are at stake. I discussed this situation with Silumelume Kufunduka Mubukwanu, a sixth generation direct descendant of Mulambwa, the first monarch of the second dynasty of the Barotse Kingdom.

"Just call me SK!" SK, a Rotarian, a former Zambian Ambassador to India, Nigeria, United Kingdom, and South Africa, now retired to his ancestral region in Mongu, listens with concern to the oxygen deficiency saga.

"SK, can you form a public trust to develop this idea?"

"Yes, but only if it serves a noble cause."

"Would the purchase of an oxygen generator, owned by the trust for supplying product the the local hospitals be feasible and noble?"

"Yes. We could guarantee the needed oxygen to all villages in Western Zambia. There is an acute shortage of oxygen for industrial usage throughout the country. We could sell any excess supply over and above our needs and turn the profits back to revitalize health care here. What capital investment would it take?"

"$150,000.00"

This project could save so many lives, create work and bolster local morale. This could be an example of social entrepreneurism at it's best, potentially exported to other sites.