My Little Buttercup, Or what happened when I visited a community health center near Bo

I wanted to see a community health center, where clinicians might have seen suspected Ebola cases three years ago. So, I asked my driver, Idrissa, whether he could ask some of his local contacts about the location of the health center in Gondama. I hadn’t been to Gondama since 2003. It wasn’t too difficult to get to, we knew. I had, in fact, seen a sign for the place when we were driving elsewhere. So, on Wednesday morning, we drove over a weather pitted road to the health center. When we arrived, a guard opened the gate to the modest facility. At least a half dozen men and a few women were in the waiting area.

Odd, I thought. My experience was that women tended to go to health centers, but not a lot of men – not because men don’t get sick or hate health centers, but because women and children are often the target of community health interventions (but that is another discussion for another day).

Two women greeted me, and nodding toward the group of men and women in the waiting area, told me that the community health workers (CHWs, they called them) were all there, ready.

Odd, I thought. Impolitic as it was to think or say, I didn’t really care about CHWs. Not today. But I did ask whether there were any female CHWs because, judging from the small group gathered, there didn’t appear to be any. “Yes, there are women there,” they said almost indignantly. I corrected myself and asked sheepishly, “But are there more men than women, or about the same number of both?” They laughed – more like harrumphed – and told me, “Well, it’s not 50-50,” a reference not to an actual ratio, but the way gender parity was often discussed colloquially in Sierra Leone’s development industry.

I followed the women – I’ll call them Amie and Fati – into an office where we sat at a table. The small room was crowded with furniture, and the walls were covered, predictably, with posters from the ministry of health related to women and children’s health. They began to interrogate me about what I wanted to know, and asked me if I wanted to look at their rosters, and when I would be talking to the CHWs who had gathered to meet me. The CHWs had been waiting and were becoming impatient.

Then it occurred to me: they thought I was someone else! (The reference in the title of this post is to that mistaken identity scene from Three Amigos, if you hadn’t caught it). I told them, “I’m not here to meet with CHWs.” I told them that I was just around and happened to come to Gondama. I didn’t have any specific questions, really, but did they happen to see Ebola three years ago? Yes, but they referred them to the district hospital. Having been a consultant once upon a time, I mentioned that unlike a consultant, I was not interested in extracting information from their registers, their CHWs or them. I simply wanted to observe. Their eyes widened. But surely, I was from an NGO. Nope, I wasn’t. This kind of admission – that you had no NGO affiliation or specific agenda besides ‘observing’ — can make you seem unserious if not untrustworthy. Everyone has a mission, whether they admit to it or not.

The facility’s in-charge, as in most of the places I visited during this short, unannounced trip, had been called to Freetown for a meeting. Whatever his shortcomings, among them was that did not give them enough information about who would be visiting, their purpose, or even the time these inquiring strangers would be arriving. I suspected that their confession was a bit of shade towards their co-worker, but it was also some shade towards the process itself: people were coming all the time to gather information; strangers like me were interchangeable with each other. The logos on our white Land Cruisers could be swapped and they would be none the wiser; the stranger could be from Boston or Washington or London, Johannesburg or Nairobi. The source of the information to be extracted was a circle of gathered CHWs or maternal registers, or immunization charts mounted on the walls or…

“Won’t you come and look at our labor and delivery area?” asked Amie. Inside the maternity ward were a couple of midwives who asked me if I too was a midwife. I told them no, but I’m a mother of two. (No comparison, though. Their work can be rough). There were four or five padded tables separated by curtains and fitted with stirrups. In a separate room, there were a few beds for new mothers who would, after their deliveries, be discharged after 72 hours. On a wall near the entrance, I read the instructions about when to deliver oxytocin, and briefly recounted the induced delivery of my daughter five years ago. Then I told them about the worried look on my obstetrician’s face when she couldn’t stop the bleeding during my second delivery. I mentioned how my son’s heart rate began to decline rapidly, how I strained to block out any semblance of panic by pushing. “Eeeeeehhh,” they said almost in unison, sucking their teeth at the very real trauma of childbirth. But the boy was healthy and strong. I would have panicked for nothing. I reached for my phone. “Yu wan si mi pikin dem?” Yes, sure, they said. I showed them pictures of my babies. Then I gave them my card and said I’d be going so they could prepare for the real guest.

They wished me luck on my quest — whatever it was. I wished for them a not-too-much longer wait for the stranger who wanted to meet with the CHWs.

Facebook reminded me that streets have names: a dispatch from Freetown

When I was in Bo on August 15, 2017, I received a reminder on Facebook that I had a appeared on Democracy Now three years ago, with Laurie Garrett and Lawrence Gostin, to talk about the then escalating Ebola crisis in West Africa. During her epic screed — it nearly left me speechless, that’s how epic and screed-y it was — Garrett emphasized that if the disease hit a “chaotic” megacity like Lagos, it would be a disaster of epic proportions.

Because there are no street maps. (Trust her: she’s been there. And oh, yes, Boko Haram.)

She might have been right about the disaster a generalized Ebola outbreak in a megacity would have caused (there’s a reason that Contagion starts in Hong Kong, no?), but where she was wrong: there ARE maps and the streets DO have names. (Yes, U2 is on tour and I plan to milk the shit out of the Joshua Tree album when it’s all said and done).

Anyway, this idea that there is a place where the streets have no name, and that is a threat to disease control efforts: That’s both beside the point and constitutive of it.

Garrett was correctly suggesting that one tends to understand dynamics of disease transmission, and therefore, of disease control, in relation to person, place and time. That’s epidemiology 101. Her mistake was in suggesting that people cannot be properly assessed in relation to their place, simply because she finds a place to be disordered, or ‘chaotic’ (to use her words). But make no mistake: somebody knows that place’s name and how to get there. And some of that knowledge is, indeed, on maps. Mental and cognitive maps, formal paper maps, and yes, GPS enabled mobile phones. (Lagosians, they’re just like us!)

This seems like a rather literal, practical and basic point, but I was so mad when she said that, that I nearly punched something. (The camera man confided to me afterwards that he was also angry and annoyed by her remarks, and he had much less invested in this whole thing, as far as I could tell). I was mad because she foregrounded her own discomfort with spaces she found illegible, and therefore, ungovernable, and projected it on to what was ultimately a successful campaign to suppress the transmission of Ebola to others in Lagos. (There are many opinions on why it was successful, but I am not here to talk about that. Let’s just imagine that it only had a little to do with the (non)failure of street maps).

So back to Bo, Sierra Leone’s second city, and capital of a district that witnessed many Ebola cases. Driving or walking around and asking people if they ‘sabi’ (know) a place is generally my way of navigating in cities and towns of Sierra Leone. This is because I am terrible with street names that don’t fall along a major public transport route, and because it’s a good way to know wetin olman sabi — what things ‘everyone knows.’ It is also a good way to practice my language, because let’s face it, if you can follow directions to “streets that have no names,” you are improving your language skills.

After visiting the district hospitals in Bo and Kenema during this woefully short trip, I realized that I still hadn’t found what I was looking for. I wanted to see what became of ETUs. I am 100% sure I missed several places, but I wanted to see how easy it would be to find them without lots of planning or asking around beforehand. I asked folks for directions to community health centers. I found two and likely would’ve found several more if I had had the time. I googled ETU locations and found a WHO spreadsheet with GPS coordinates. I followed one set of coordinates to the wrong place, those ‘coordinates’ being the name of the place itself. And then, using the GPS on my phone, I followed the coordinates to a neighborhood where residents were pretty sure there had been no ETU. (The coordinates led to very small parcel of land beside a hotel). But when I talked to staff at the health centers, they would point in the direction of a place and name its location, explaining their place’s relationship to that place.

What does any of this mean, and why does it matter? For me, this trip to Sierra Leone was about wayfinding and orientation; there was no plight (as Auntie Mary, an in-charge at one of health centers called it) or mission, besides finding “there” — which seemed to change every few hours each day — and hearing what people had to say once I got there. Perhaps a fancier way to put it is that I am processing the ways I am reading landscapes in relation to others’ own readings, and the ways that landscapes are subject(ed) to “local” memories. How does this stuff matter for people in the everyday?


Developing an analysis plan (ethnographic data)

The other day, I found myself overwhelmed by the amount of data I had collected over the past four or five years for my global surgery project. I’m trying to finish up the book proposal, and I realized that there were bits of data that I hadn’t taken into consideration: should that stuff be in the book, or should I write articles? Should I just assume that none of those materials would be used at all? After mulling it over, I decided I would create an analysis plan. Back in the consulting days, when I designed and coordinated survey-based data collection (and charged cash-strapped NGOs a daily rate for my services), I had very little time to collect and analyze data and write up my findings. To stay within budget, I would usually take a couple of planning days to develop an analysis plan — not only to get clients on board with the scaled back version of their overly ambitious terms of reference, but also to make sure I could write a useful report quickly and as thoroughly as these short timelines allowed.

I’ve since moved on to “academic research” using primarily ethnographic data (which, yes, can include surveys, but in my case, usually does not). But I think the analysis plan template remains the same. Here, I’ll use my Twitter data as an example, even though it is probably the “rawest” and under-theorized part of my data set. (In other words, I think there has to be more said about what Twitter as social data and as social practice can tell us about specific, evolving social phenomena. But that’s another story for another day.)

  1. Decide on an overall timeline for preliminary analysis. I would like to complete preliminary analysis in 8-12 weeks. This means that each of the column headings below will correspond to a week or set of weeks.
  2. List all sources/types of data (can be two columns, e.g. Twitter, tweets). I have “scraped” twitter on my topic for over four years, using a google script. The script has produced a fairly large spreadsheet full of tweets, with some basic information about each of those tweets (RTs, Faves, etc). I also have collected odds and ends on Evernote (screenshots, radio interviews, photos, maps/images),  compiled field notes during participant observation at meetings, written detailed notes on interviews, created a database of documents from various archives; and transcribed and translated interview transcripts. Each data type/source corresponds to a set of research questions that I came into the project with. As the project evolved, I added more (sub)questions to add texture to observations.
  3. Link data source/types with specific research questions. For my Twitter data, for example, I have the following questions: How, if at all, do my interlocutors on this topic (hashtag) use Twitter? What topics do people tweeting under this hashtag write about? What types of people are in the networks coalescing around this hashtag? How has this group changed over time? Who are the nodes in these networks? Has this changed?
  4. Add new sheets as needed. Other issues with analysis and collection may arise as you sort data piles and link them to their proper set of research questions. In the case of my Twitter data, I realized that I may need to reach out to more people for interviews so I added an “interviewees” sheet.
    • This question came up as I scanned the list of tweets and the most prominent Twitter handles: have I talked to these people, or researched the material they have made available about themselves?
    • The interviewee sheet includes columns like ID, Name, Title, website, twitter handle, link to interview notes or transcripts. (I also have an “interview” data source in my general list, so this is helpful for tracking those data).
  5. Finalize duration allotted for this piece of analysis. As far as timeline goes, I have decided that I can handle this set of Twitter questions in three weeks. (if you’re fancy, you might create a Gantt chart, or link this to an Asana project, so that you’ll have a nice visual representation of progress on the project). 
  6. Follow your plan and update as necessary. Flexibility is key!

So, this is a rough sketch of my plan. I believe it could have better/more detail that would allow for tracking themes, but I’m relying on my work in Dedoose for this. Do you have an analysis plan template? What does it look like?

Using short-form writing and audio to build critical skills

This semester, I’ve been testing out several new kinds of assignments. Reading themes, podcasts, blogs. All are to get the students thinking about how to be observant, critical thinkers and how to communicate their analyses. Each of the exercises builds into one big final project: a This American Life style podcast. (Yes, I know. High expectations). For this reason, our discussions and mini-assignments are largely focused on building skills that allow them to read difficult material and listen carefully, recall and recount what they read and listened to, and to find links among stories, events and processes that are not always obvious upon first glance. Ultimately, they should be able to carefully observe their social worlds and analyze what they see in new and exciting ways. Here’s an overview of two of the assignments:

Reading themes. Each week, the student submits a word or phrase that illuminates one of the following:

    • A keyword in a conceptual or theoretical framework used by the author. For example, we read Tim Burke’s Lifebuoy Men, which grapples with the utility of Marxist theory for historiography (use-value, exchange-value, false needs, commodity fetishism) and the ‘social life of things.’ Students would then post some of these keywords and be expected to discuss and define them in class.
    • A theme that reveals the kinds of ‘conversations’ the author is in. For example, in this same book, it was clear that Burke was also dealing with a social science literature that sought to follow a commodity and the cultural meanings associated with it: in short, the social biography of a commodity.
    • A keyword or phrase about which the authors are not explicit, but which raises new questions for you and the reading. This is that sophisticated layer of analysis that takes a bit more time, and often a larger reading repertoire, but something I hope will happen by the end of the course.

The reading themes are then put in a word cloud. Frequency of terms reflects the issues that students tackled as they read the text. These word clouds guide the lecture and discussion. As you can imagine, there are also lots of words that never make it into the cloud. It’s my job to figure out what got omitted and why, and to address these in the discussion. 

Week-in-review podcasts. I got the idea for this assignment from a communications and rhetoric professor. Each week, a group of students pair up to create a five-minute audio summary of what we discussed in class. It serves two purposes:

    • Students learn how to take a relatively large amount of information and condense it, making it digestible for an audience of their peers. In theory, they are also learning to make decisions about what is important and how to organize various insights into themes. (This has been the most difficult part so far, but I am working on shifting that a bit). 
    • Students have a lower stakes opportunity to experiment with developing audio content from writing to recording to editing.

So far, I am thinking about how to better integrate students’ week-in-review podcasts into the teaching and to ensure that the word clouds become more than just a pretty depiction of word frequency for the students. I hope to post more information as we get deeper into the semester.