A Discussion with Tom Dannan, Executive Director, John Dau Foundation
Background: In an interview conducted on June 16, 2011 between Tom Dannan, Executive Director of the John Dau Foundation, and Anny Gaul, of the Berkley Center, Dannan recounts the origins and operations of the John Dau Foundation clinic in Southern Sudan and focuses on their work with traditional birth attendants. He reflects on the pros and cons of working with midwives versus traditional birth attendants. He highlights the practical and cultural obstacles to encouraging women to come to facilities to give birth, and especially the challenges of sustainability. Gender issues, including bringing men into work on maternal welfare, need attention.
Interview Conducted on June 16, 2011
Talk a bit about how the John Dau Foundation came to be.
As of the "Lost Boys" of Sudan, John Dau was given a visa to resettle in the United States in 2001. Nearby to where he settled in upstate New York was a small church, First Presbyterian of Skanaeteles, of maybe 200 people or so, that supported several mission projects. They became involved with the group of Sudanese refugees by taking the boys out to lunch every Sunday. John was featured in an award-winning documentary, God Grew Tired of Us, about his journey from the refugee camps to the U.S., which resulted in a lot of publicity. So he came to the church and announced he wanted to build ten clinics back in Duk, his hometown. The church put together a task force and said "well, let's start with one clinic and do it right, and then we'll take it from there."
They put together a board including a former CEO of a medical supply company, a few doctors, businessmen, engineers, and people with overseas experience. Drawing on their various talents they put a project together, raised the money through donations and through John Dau's speaking engagements, and in 2007 they opened the John Dau Lost Boys Clinic. It's been operating ever since.
How does the care offered by the John Dau clinic differ from other health care providers? We have talked about the fact that it simply exists where no other group is willing to work; but what are the unique ways that you approach care and measure your impact, for example?
I think as an organization we have always been really focused on making sure we provide a quality product and for the basic, most critical needs - maternal and child health. It has become a spiritual and a personal issue for those involved: we aren't interested in just checking off boxes and meeting certain criteria so much as simply delivering a quality product, which has meant that sometimes we have done things a little differently.
For example, many NGOs only bring in foreigners on a very limited basis and emphasize employing Sudanese as much as possible. For us, however, it was difficult to find qualified local people to staff the clinic. So at the beginning, our staff was all Kenyan, with a number of American visiting medical practitioners who came in every so often for trainings. Hiring Kenyan staff was contrary to what a lot of other groups were doing, but it allowed us to hire people who were better trained and more experienced. A lot of people raised their eyebrows at us initially, but by expanding and being willing to hire anybody, we've been able to develop a quality product. As time went along and more Sudanese were trained, we started working on capacity building and hiring more Sudanese. Everyone we employ now is incredibly committed and hardworking because we've established that kind of atmosphere: that we're going to establish the best clinic, period, and not set boundaries such that we can only hire Sudanese. And it's worked for us: now we have only 3 Kenyans on staff and 21 Sudanese, a lot of them locals who have been able to come back to the area because of the project.
And we'll be there until our bank accounts are down to the last dollar. The staff who are there really believe in the mission. They are really committed to the place and to the project, and I think there's a spiritual basis to that. There's a real espirit de corps within the group, especially as an independent mission project.
How do you approach working with local traditional birth attendants (TBAs)?
One of the locals we've hired is an outreach manager. He and his family are well-recognized in the community, so we send him out to make contacts with TBAs. People do realize that the clinic is the only medical institution around, and they know we provide quality care, so they're usually willing to help us out with contacts and communication. But there is still a lot of suspicion of the newer health care, especially when it comes to mothers and delivery. If I had to name on thing people are most skeptical of when it comes to new services, that would be it.
In South Sudan there is a general policy that when working with limited resources, it's best to invest in long-term, sustainable solutions - which TBAs are not, in the opinion of the government. For that reason, many people would rather spend money to train midwives rather than TBAs. I think there is a similar outlook in many other places, in Africa and elsewhere. The predominant messaging these days is clear: TBAs are not the way forward.
But then again, there are enormous challenges to training midwives, as opposed to TBAs. Our partner, International Relief and Development, was asked by the local ministry to host an 18-month midwife training. They sent out a call for applications, expecting a class of 20 or 25, and they got only one application from the entire state, the biggest state in South Sudan. Just one. So we view work with TBAs as a practical measure.
In Sudan, the only people who are accepted for midwife school are people who have graduated from high school, so that makes it tough. There's an important gender element as well. Many of the midwives who have been trained are males, and people will trust a trained male for the most part, but we have a lot more antenatal care visits and a lot more deliveries at the clinic when there are females working in the maternal and child health department. And often women do come in accompanied by their TBAs, who of course, are all female. But in the county where we're located, 80 percent of the 3,000 deliveries per year happen more than 10 miles away from the facility. It's just not practical that all women will come to the clinic to deliver. So we do conduct TBA trainings and distribute safe delivery kits.
To organize the trainings, we'd send out our local outreach person with the backing of the clinic, which is generally very respected. He would talk to the chiefs, the local leaders, and ask which TBAs in the community were the most trusted. The communities nominated their own TBAs, about 3-4 from each area, for an initial group of about 26. We trained them for a week and gave them safe delivery kits and other supplies.
The first training we did was run by a Kenyan midwife who had been with us for a month. This was the first formal training these women had ever attended; many of them had never gone to school. Many of them, with certificates in hand at the closing ceremony, said that the first child they delivered would be named after the midwife who'd trained them, Julianna. And while we paid the midwife a pretty competitive rate, there's also that mission aspect that helps us to motivate people to come work with us. We've had follow-up trainings of a few days each to give out more supplies like flashlights and gumboots and to add information that the TBAs themselves have requested, for instance, teaching them to recognize signs of malnutrition among children.
What do you think it is about childbirth that makes mothers in labor or their families so reluctant to seek facility-based care?
I think it's such a natural process - obviously, it's been happening since the beginning of time - to the extent that people really build their social institutions around it. People will still go to traditional healers if their child has malaria, too; it's about comfort and familiarity. But people in our area also know that in cases of severe illness, often there is no option but to go to the clinic.
When it came to childbirth, though, we used to get only two or three facility-based deliveries a month, so we reevaluated: we hired a woman to work in the maternal and child health department and put up privacy curtains on the windows of the clinic. It's really a comfort issue: when women are giving birth they know that their life is at risk, and coming to the clinic means you're entrusting your life to somebody. It's difficult to go to the clinic to entrust your life to someone you've never met before, especially if it's a male who's not your husband. Women will often only come to the clinic as a last ditch effort, when there's a delivery that a TBA can't handle. One thing to keep in mind is that while marrying cousins is not practiced in South Sudan, a woman can't marry a man if her family doesn't know his. Some level of familiarity is essential for entrusting a woman's well-being to someone, so a male stranger at a clinic isn't going to be a woman's first choice when she's giving birth.
What are the biggest barriers to access?
Cultural issues are not really our biggest hurdle. Maternal mortality is incredibly difficult; even though a lot of mothers do pass away, and these deaths are accepted as a part of life, people aren't just shrugging their shoulders at it. Recently I was at a funeral of a mother who died, and the family was inconsolable. So people know that something has to change.
Logistically, though, the area is very spread out - most patients come from a day's walk away or further, on roads that aren't paved or passable during the rainy season except by walk - a very slow, dangerous walk through mud and hostile areas. There are also many families and villages that have just been on their own forever; the idea of living in a big town or a city is very new. And so although we have enough staff, supplies, and space in the clinic, the logistical barriers are enormous.
We have a Land Cruiser that functions as an ambulance, for example, but there's such a big need that if we get a call from a village that's more than 15 miles away, it's often too much of a risk to the vehicle - it's all dirt roads. There's no cell phone reception, just satellite phones, but it costs a day's pay just to make a short call. People are using CB radio more often, but if a call comes from too far away there's just nothing we can do. And during the rainy season, for six months of the year, everything is so flooded that we literally can't drive the vehicle off the clinic compound. If someone comes from far away during the rainy season, they have to walk through knee-deep water. Of course all of this points to the importance of preventive and antenatal care.
For example, we don't have any surgeons on staff, so if there is a case that we can't handle - say a C-section or a fistula - we have to evacuate the patient. We have supply flights that come in every month or so, so we try to coordinate with all the mothers who come in for ANC and have some indication that they'll need a referral - a C-section scar, for example - and let them know when the next plane is coming so that they can gather their things and be taken to an appropriate facility. If there's a real emergency we'll also call African Inland Mission (AIM) AIR, a missionary organization with volunteer pilots that fly small supply planes, and see if there are any planes in the area.
One time we really lucked out: we had two expectant mothers in need of emergency surgery, and there happened to be a pilot with a plane just to the south who was able to pick them up and drop them off in the capital. But the cost of that flight alone was a thousand dollars - which was at a steep discount; all those pilots are volunteers. And the foundation absorbs that cost. We have had churches in the U.S. donate to a small fund for those emergency flights.
The toughest part of my job as a director is when the clinical staff says, for example, we have to refer this patient: she's bleeding too much and clinically, in this situation, when the problem is beyond your training, you're trained to refer it. That's your first reaction. But then you look around and see that the road is flooded, the security situation is insecure, so you can't travel at night...sometimes logistically there is just nothing you can do.
Again, prevention and antenatal care can prevent so many unnecessary deaths. It shouldn't come to that. Working referral systems can solve so many problems.
What are the most effective partnerships you've found?
There is a group called Hope of Sudan Alliance, which is a loosely affiliated network of church and mission groups. Often churches are taking in a lot of refugees, which is how this type of work gets started. We are one of the 3 or 4 biggest Lost Boy groups in South Sudan, so we get a lot of inquiries. A lot of new clinics contact us for advice; it's an informal partnership.
Additionally there are our funding partners. When we first started, 100% of donations went towards programming, but as we grew we had to start paying salaries and overhead. So we started working with organizations like International Relief and Development, which is a bigger NGO based in Washington, DC. We have a grant from them from the Basic Services Fund of DFID, which we needed as donations started drying up. Those initial donations were intended as seed money, rather than a long-term source of funds. We also try to coordinate with other NGOs on the ground near us - for example, Catholic Relief Services, which funding another group in our area. We also partner with UN agencies like the WHO, WFP, and UNICEF to provide supplies.
In terms of private public partnerships, the local county health department is somewhat fledgling, but we try to coordinate with what they're doing. They don't necessarily have any strategic directives for us. The Ministry of Health in South Sudan is interesting because the way that ministries were divided up was so political: each political party was given control over one ministry or another. So political affiliation, rather than expertise or concern with medicine or health, often determines who is working for the ministry.
Do you see any major changes after independence?
Honestly, since the 2005 Comprehensive Peace Agreement, the South has pretty much been running things on its own. I think people are prepared for the transition; everything will more or less continue as is. Even before the referendum, people saw independence as an inevitable outcome. So not too much has changed.
What are the biggest challenges of your work?
I think sustainability is the biggest challenge for both faith-based and secular organizations. Some do a better job with sustainability than others; for some organizations, it's just an afterthought. I think far fewer people are actively working towards sustainability than those who claim they are. In terms of mission-based groups in particular, it seems that they often go back home every few years to make a pitch for continued financial support of their work. For some groups it's just automatic, but in our case, as in many others, I think donation-based support for the project was always pitched, as getting something started that could eventually be handed over to the local ministry of health. But the ministry is taking a long time to really get going, so finding sustainable funding options is a huge challenge. Because of their nature, I think a lot of Ministry and Mission projects tend to work at the grassroots level, which you could argue is more sustainable.
What are the biggest knowledge gaps in terms of faith groups and maternal mortality?
It would be interesting to see how people are using the framework of gender sensitivity to work with all parts of society. So often we think of gender sensitivity as including women and girls, but it's so important to include not just girls and women but men, older men, boys, and the elderly too. If you're working with a women's circle that focuses on breastfeeding, it's important to work with men on the same issue, especially if they're the ones who have the money and will be the ones buying formula. The relationships between older and younger women are crucial as well. To make change requires engaging every aspect of society. Bangladesh seems to be a great example of working towards that when it comes to reducing maternal mortality. It would be interesting to see what strategies have worked to engage men on the issue, as faith institutions are, by and large, run by men. And church leaders or other religious leaders in many cases won't stray too far from the opinions of their congregations; in many cases religious leaders are chosen by their communities. And often, chiefs, politicians, and other secular leaders work the same way: they are in leadership positions because they are respected, but they are also chosen by that community. However right or just we think our cause is, we have to engage everyone in a community to really see change happen.
I would also be very interested in seeing more research on the benefits of task shifting. There are so few people who perform C-sections or fistula operations, for example, but some countries are starting to ask if we can train a midwife or a nurse or a physician's assistant to perform them. Obviously these are complicated procedures, and in the rush to provide services you never want to sacrifice quality. But at the same time, a midwife or a TBA might be the only attendant available in an entire county. I’m not a clinician so I can’t say in terms of ethics what is right or wrong in terms of what task shifting might be appropriate, but it would be interesting to see what has been tried.
Lastly, it takes a lot of money to build a clinic, but there are a lot of low-cost interventions out there. I’d like to see more examples of how people are using limited resources creatively.