Firuza Harsanova

Health Education Specialist (Health Education Program - Sumgayt)

Been working with MSF-B since 1996

Nationality: Azeri

Can you tell me a little bit about MSF's program to train students to be health education trainers? We started teaching children about health education. We were also working among the adults, training keypersons to be health educators. Then I thought it will produce a good result if the students will learn about the issues and how to teach them, and then will teach the younger children. The children from the other classes - 9th to 11tth - they learnt the topics themselves, then went through a course on "Train the trainer" and have begun to teach the youngest children. And this has so far given very good results. What is the difference between an adult teaching children or children teaching their peers? The children understand better if other children teach them. They have their own attitudes, their own language_they understand better than when adults come and teach them. When you started training these children to be trainers, did you have any difficulties? We had some difficulties. They didn't know about teaching methods, but I gave them examples of how to teach and they learnt how to prepare lessons. When you are sitting in the health education classes taught by children, and you listen to the response of the children, what are the comments they make? They observe the presentation that was made and they evaluate it. They say what mistakes their friends made. For example, a trainer used only speech and not other methods of teaching such as demonstrations, their teaching seems like a lecture. The children can use demonstration methods and some of them are so afraid about whether these will be good or not. Many haven't done presentations before. Some children are going to be the teachers in future so it is great experience for them. They must gain a lot of confidence when they do successful training? Yes. During our lessons they understand the importance of the health education. If they will learn the courses, it is useful not only for them. Even if one child gives passes on the information to three other children - it's good. They are in the community, they are with their neighbors, so if one child has diarrohoea, they can give a recommendation on how to stop the diarrohoea, how to treat the child at home. The children say they give the information from the classes to their parents all the time, and each time the parents are very interested. They also pass on the information to their neighbors, even to the teachers in the school, and every time the neighbours and teachers are very interested.

Amal Mekkioui

Manager of the Health and Education programme, Sumgayt

Been in Azerbaijan two years

Been working for MSF since December 1998

French

Why have you chosen to work in Azerbaijan? I'm interested in the country and in the culture, because in the beginning I thought it would be close to mine, because I'm from Moroccan origins, but there is really no similarity. So it's a kind of curiosity as well that makes me stay here. Culturally and socially its very interesting to be here because it's not Europe, it's not the Arab countries, it's not the Muslim countries that I know. Can you give me an example of how culturally it's interesting? They are supposed to be Muslims here and I am Muslim as well, and I always thought I didn't have that much knowledge, or only a basic knowledge, about religion, and I have met a lot of people here and they say they are Muslims but they don't know anything about it. So it has been very interesting to see Islam in a different eye. My conception and theirs is totally different, and this is what I have found interesting. Can you highlight a particularly worthwhile aspect of your work in public health in Sumgayt? Well the program is important as you have a feeling that there are some basic things that every person should know about health- which any person in Europe would know for example - but here it seems that people don't know. At the beginning you think, what is health education, what does it bring to people? But when I see the results, the health education in schools for example, and also with the IDP women, when we go to the buildings where they live on outreach work, then you can see that they are interested and they are eager to know. It is clear that it is not that easy, because you are the European and you are coming to bring your knowledge_and you have to find a way to introduce this. It makes it easy that we have Azeris with us (keypersons who teach the groups), and they believe in the program as well - that's very important, and they are the ones who can explain the idea of the program. I have the feeling that I am doing something. Maybe it's not the most important program in all our projects, but it's not the least important either. It's an important part of the programs of MSF-B, because if you want people to go to our dispensaries, then you have to explain things. It is necessary to convince people that they have to pay attention to their health, so it's an important part of the programs. Can you think of a particular situation where you remember really thinking you could see the value of the work you are doing? I remember my first visit in a school and I went to the class to see our new children keypersons (children trained to teach their peers) who were around 16-17 years old and they were teaching the younger ones. And it was great because they were taking their task very seriously, and they were teaching the other children something which was important for them. Our aim was to teach the keypersons and then for them to take over, and this is what they have been doing, and doing it very well. When we see this we are very happy, because then you have a reason to go on - because if they believe in what we are doing then they can convince the younger ones. This is not always easy but they can do it - they know the language, they know how to explain things to the children, some of them are their brothers, cousins or whatever, and for them maybe it's easier to give the message of health education. And how does the class react to the keypersons' classes? Very well. Here they study a lot, they learn everything by heart and they are eager to answer the questions, so each time a keyperson asks something, the children want to answer the questions. And when we spoke with the class, they all wanted to be teachers, so it's a success in a kind of way because we taught them how to love to teach and apparently they enjoy it. It works, the children are very active, and the students all take it very seriously - there is almost no absenteeism in the public health classes, they never forget their books, they always prepare stories about disease or whatever. If they have homework, they will prepare it and they will be eager to show you what they have been preparing. This is very pleasant. What is it like to work in Sumgayt? I see it differently now. At first, you just see everything as totally devastated, but then you get to know the people, and when you go to their places and they welcome you, and then you start to see things differently. I don't see the ugly landscape anymore, maybe I try to forget it as if you notice it too much you will get depressed, but you just tend to see the good things in the place, I try to, and to think about how we really can do something here. When you first arrived in Azerbaijan, was there anything which took some adjusting to? Well, the mentality is different, it's not easy. When I say that I am French, it is difficult for them to understand this - they need to know your origin, and as far as I'm concerned, I'm not coming from Morocco, I'm coming from France. There was quite a lot of racism actually. If you're not blonde, it's more difficult for you, and especially if you look more Arab. For me it was very difficult at the beginning to confront this, but now it's fine. They didn't greet me, or they called me "chorny" (black), but I didn't ever have this problem with the refugees. As soon as I was far from Baku, I didn't ever have a problem with this, I have never had to actually say where I am from with the refugees. I speak French, so for them I am French and that's it. I can't really understand this - maybe because in Sumgayt, I have the role of the manager and I work for MSF. In Baku, I just meet people, so they don't think about who I am or what I represent.

Judith Kloiber

Survey Administrator, MSF, Azerbaijan

Working with MSF-B in Azerbaijan since March 1999

German

Working on a survey about STDs in Sumgayt, Imishli and Saatli What was something that you quite surprised about when you first came to Azerbaijan? The first time I came to Azerbaijan was in December last year for a few weeks. I was shocked by the pollution you see in Baku and around Baku - the oil riggs and pipes everywhere. Why it is important to do an STD survey in Sumgayt, Imishli and Saatli? MSF has been working in the field of reproductive health and family planing in Azerbaijan already for many years. What we have found is quite a high infant mortality rate, high numbers of abortions as well as poor knowledge about contraceptive methods. The prevalence of STDs in this country has seemed to increase during the last few years, like in other former Soviet countries. So in the MSF Imishli program of activities, a pilot project for the treatment of STDs was started. This means that the gynecologists and dermato-venerologist of the Imishli Central Hospital were convinced to treat their patients according to the WHO syndromic approach, of course in agreement with the national authorities. But to guarantee good treatment, the WHO approach has to be adapted to the particular situation in Azerbaijan. And therefore we are going to start our survey, to get reliable figures about the sexual behaviour of the population, the current ways of STD treatment and the resistance towards antibiotics, etcetera. What was a surprise for you when you started your work with MSF? When I visited the MSF projects in Sumgayt, and went to the industrial part of the city, I saw how the people are living there, the air quality was really bad. Also, some weeks ago I went to the field, to a hospital - it was really poor, it had nothing, you couldn't see any patients, the doctors didn't have any equipment. I can understand why people don't have any trust in the public health system right now, they don't like to use it, but sometimes they have to. What was a pleasant surprise? I was pleasantly surprised in Sumgayt when I went to the MSF dispensaries, and saw some nurses from MSF giving the general health education training to local people waiting for their appointments. I was really surprised at the positive response from the patients. People were really interested in the topics such as contraception use and malaria. For have you personally enjoyed so far about your time in Azerbaijan? What I really like is that the people are so hospitable and friendly. We have spent much time together with local people, very nice evenings - having dinners, talking about our countries. That's what I like.

Sanam Hasanova

IDP Woman Living in a Train Wagon Imishli, Azerbaijan

• 46 years old
• Used to live in Nagorno Kharabagh, fled in June 1993
• Has been living in a train wagon in Imishli, Azerbaijan for 6 years with her mother
• Works as a school teacher in the local school
• When she lived in Nagorno Kharabagh she had her own house with 8 rooms, a yard for animals, and she worked as a teacher

Can you describe the day that you had to leave Nagorno Kharabagh? People had no opportunity to pick up their bags. They weren't informed that the Armenian army was going to occupy the territory. It was a really big tragedy. Some family had cars - they could move to other districts. When they moved they didn't know where to go. They went to their neighbors, some people stayed on holidays, it also depended on their possibilities - some one of them stayed here, in comparison with others they had no opportunity to move. Nobody expected they would live in such conditions for such a long time. Can you describe the conditions where you live? During 2 years I was jobless. It was difficult to find a job, but we received money from the government and humanitarian aid. Now I am working as a teacher. I have a job, and compared with other families, they live in worse conditions then I. Also the humanitarian aid people receive is not enough. If they get 5 kilos of flour once a month, this is not enough. The people here are trying to survive by themselves, trying to find jobs, they help each other, some of them have relatives - that's the way they survive. How does it feel to be living for such a long time in a situation which many think is temporary? Of course everybody who lives here would like to return. It is like a stigma to be a refugee. Sometimes the refugee population do not live very peacefully together with the local people. Many people don't have anything. Some of the refugees had a lot and right now they have nothing ... How many years will they live here and have a useless life?

Susan Rathe

Responsible for Reproductive Health Programs

Been in Azerbaijan 3 and a half years

Working for MSF in Azerbaijan since November, 1995

Nationality: Swiss

Can you outline some key points about your work, which you consider valuable for the people of Azerbaijan? All kinds of health issues concerning women still present a difficult situation in Azerbaijan. Access to medical care is not obvious everywhere. And maybe due to their Muslim backgrounds, women are kept at home and it is not obvious that they would be taken to the doctor. Because of the economic crisis, it is very often difficult to be able to afford to go to the doctor, and when I came here there was practically no modern family planning available in the country. What women mostly used was abortions and very often back-door abortions, because they cost less than the official ones - it's legal to go for an abortion in Azerbaijan, but it costs quite a lot if you have it done legally. So this is what we begun with - we tried to offer alternatives to these abortions. Then we gradually extended - trying to improve all the obstetric practices at a village level in order to offer better services for the women in the villages. And then we extended to other gynaecological services. Under the old Soviet system, it was arranged so that there was some kind of medical person in every village. On average, you would find one midwife per one thousand inhabitants. Those were the people who were sought out for medical help, not just for obstetric help, but for other things as well, as they were the only person who had some medical training in the village. So this system was established, but these people worked without equipment, no drugs, no supervision, no additional training or these women could not attend the training as they were wives, mothers and farmhands as well and they also had the village to look after. So if you took them away for a refresher course, everything in the village would have collapsed. So, given these circumstances, we thought to introduce regular visits to these midwives for supervision, for training and supply of equipment to allow them to be able to do what they were supposed to do under better conditions. Can you think of a specific example during your work where you really thought to yourself that it is worthwhile? This happens regularly. We have built up this reproductive health system in 2 districts - it's now under the supervision of 2 local doctors, and it works. All the midwives are participating. They are coming for the seminars and we have regular outreach consultations of the governmental gyneacologists going to the villages to do consultations for women who cannot afford to go to the central hospital - and these are things that did not happen before, and they now work automatically. It is also integrated into the functioning of the governmental services. The biggest challenge for me was to encourage the government staff to care for their population and to take initiative. For example, the Chief Gyneocologist of the Imishli region. I first made contact with her as I wanted to work with her developing a family planning program. When I first met with her, she was a frustrated woman who had worked for 20 years in a maternity department with staff who were difficult to work with - very corrupt, not listening to their chief - so she had practically retired to her room and had as little to do with her staff as possible. So we started to talk about family planning, and gradually she agreed that something may be possible. And then we got permission from Baku to undergo training together so that afterwards we would have the authorisation to build up a program in the region. After some hesitation, she did come to this training, and she went back very enthusiastic after seeing a sample of a family planning clinic. She went back to Imishli, and she talked with the chief doctor of the region and she said 'I want a family planning clinic in this hospital as well.' And under their own initiative, the two doctors together gathered the money needed and they used part of the maternity wing of the hospital which they weren't using anyway, and they installed a new family planning centre. This centre was more beautiful than many houses in the region! They made all the publicity about it and she opened the family planning centre. And when the Ministry of Health at the central level heard of it, and called and complained, they said we have opened it, we see a need for it and we will definitely not close it again. So you'd better accept it. So this shows the change. And she used to stay, and she still says, if you Susan have come from so far to care about the women of my region, I should be ashamed if I don't do as least as much as you. And now she is motivated, she likes her work and she does a great deal of news things that she never did before. How has speaking Azeri helped in your work? That it helped was quite obvious for the work with midwives in the regions. This work would never have been possible with a translator, because these are very personal relationships. We not only talk about pure work, but about their houses, children etcetera. It took a while to build up trust and a feeling these talks would be confidential. In the very beginning I tried to find out something about abortions in the region. I made conversation with some midwives and asked 'how many abortions happen in your village in a year?'. After 5 minutes the midwife told me that it is about 2, after 10 minutes she said 15, after 30 minutes she said 50, and the next time she said 200. They have to be sure that you won't tell another person about it and will keep it confidential.