How do we "wrap up" our experience?

The big group has now been "home" for a few days. Home is relative as Minnesota is not home for everyone -  I think all but Ken have made it to the States though. We left Ilula on Tuesday and made it safely to Dar where some went on to vacation in Zanzibar and others spent the day in Dar at Slipway (a shopping center on the ocean) and the Bongoyo island. 

I have been thinking a lot about how to "wrap up" the trip in a blog post but it has been a challenge. This year was a quick trip to Ilula for me and it felt fast. I have been grappling with what this quick in and out trip meant to me, to the students/learners and to the Ilula staff and patients.

I asked the students to tell me how they would explain the trip in a few sentences and have one to share in particular: "With every adventure there is always it's ups and downs and we had many of both on this trip, especially emotionally. I, for one, am new to the healthcare world and was thoroughly unprepared for the sheer gravity of the helplessness I felt in many situations.  However, though we were surrounded by so much suffering and destitution while working in the hospital and traveling through the bush, the Tanzanian peoples never ceased to amaze me with their overwhelming hospitality and generosity. Though some of the practices in the hospital gave us pause, learning from the Tanzanians in regard to their attitudes is paramount and I hope to carry this completely selfless lifestyle into my practice back home."

I don't think I am off base when I say that each year a lot of American staff and learners feel helpless. It is a frustrating situation and a heartbreaking one at times. But I liked the hope in her message as well - the references to living our lives more like the Tanzanians. What a powerful hope to take away after being in Ilula for nearly 6 weeks. There is still lots to be done with our relationship in Ilula and the care they are able to give to their patients but also a lot we can take away from the experience into our own practices - Shoulder to shoulder. I came to the final conclusion that there is no way to "wrap up" our experience because these trips to Ilula are life changing and the process of digesting the information you learned, the things you saw and the things we witnessed, is life long. 

The Other Side of the Coin 5Feb2016

All those things I said in my last post were absolutely true.  Today’s experience has had a substantial mitigating effect for me.

Sravanti has been working with Anne since Randy left.  Anne has substantial experience with clinical research and, hence, the IRB.  IRB stands for Internal Review Board.  This board keeps our patients safe from our intrusive eyes.  And thus protects us from breaking HIPAA rules.  Believe me, this is a good thing.  And on our better days, we all acknowledge that.

How does this relate?  The CTC Clinic (Care and Treatment Clinic) was built in 2006 by the Clinton Foundation and in the last couple years, as the clinic has been up and running, USAID has been supplying medicines and testing.  When Randy was here working in the CTC for HIV positive patients, he began looking at the computerized data which go back to 2006 when the clinic was started.  He discovered some interesting things.  The rub is that the data have not been “scrubbed,” that is, the identifying data have not been deleted.  However, after Sravanti and Anne looked at the computer program they found some summary data that had no identifying data so they could collect some interesting information to evaluate.  This will help design a study that can pass the IRB scrutiny.  But this is not about the study.

It is about the relationship between Sravanti and Anne and the CTC staff who were so helpful in working with them with the day-to-day learning that they did.  Anne and Sravanti were so happy and appreciative that they invited the group for lunch at the guesthouse. They invited the five of them.  We were waiting after lunch wondering why they had not come.  About 2 pm or so they trickled in.  All ten came!  Pole sana!  Lunch was gone.  Still, it was a lovely visit, the wazungu expressing gratitude and Tanzanians sipping sodas.

There are other bright spots too.  There is a Hypertension and Diabetes Clinic weekly.  They are focusing on these diseases.  We do not well know the tropical diseases, but I promise you we are experts about hypertension and diabetes!

Randy told our Tanzanian colleagues that they should “count things,” the importance of which was reinforced for him by one of Atul Gwandes’ books. 

Dr. Kawono with the run chart

Of course, counting things is the first practice in making things better.  A couple of years ago, I suggested a run chart of sorts.  It was just a visual representation of the data reported at morning report: discharges, admissions, births, C-sections and so forth.  I got no traction.

This year, I presented the idea to the MOIC, Medical Officer in Charge, Dr. Sovelo and with a little background from hearing Dr. Randy talk about “counting things,” I found him very receptive.  Dr. Kawono was enthusiastic too. He and I discussed what we might track.  We got a big white board, taped it all up and made dates, days and categories for the staff to start “counting things.”  We invented some categories we thought might be of interest and left a few blanks for the staff – all the staff – to think of more categories. 

It's a start!

Chaplain Kikoti mentioned he had heard and wanted the staff to know that there is cholera in Iringa.  They will count cases of diarrhea to see if there is a spike suggesting cholera has hit Ilula too.  I hope a subtle spin-off might be a reminder of the importance of hand washing.  Whatever they choose to follow, I hope they will do so for a month or two for each new item.  Then if no value, think of a new category and replace the old one.  I hope their enthusiasm does not wane.  We are trying to model and instill a culture of learning. It would be wonderful if this began a culture of “counting things.”

A Poignant Plea for Palliative Care and Existential Questions 4Feb2016

Although we have struggled each year with the realities of Ilula, this year it seems especially acute. The backdrop of this experience with the learners and faculty is the extremely resource-poor hospital.  For example, medicines are not supplied by the government as they should be. Or other supplies like lab reagents, the lack of which idles essential machines and thus cannot provide the tests that could guide our care if we had them.  We can live with this and depend on our clinical acumen and our Tanzanian colleagues’ experience.  This accompanied by the helplessness we feel when our patients die, sometimes because we do not know the correct treatment and do not know the disease we are treating.  We name things as best we can and work from there.

We sometimes do differ in therapies from our colleagues too.  In Ob, our learners have made the diagnosis of pre-eclampsia a couple times and the doctors seem to be slow to respond.  This tries the physical capacities of the two patients, mother and baby.  The wazungu look on in pain, so aware of the differences in approaches to care.  We are used to being so much more aggressive.  The choice sometimes comes down to precious resources at a full (US) course of therapy or several partial courses.  Which approach helps more patients in this resource scarce environment?  We have only our biases to support our opinions on this.  It will stay this way until resources are adequate.  There are advances here including a significant drop in child and maternal mortality over the past half dozen years.

We have smart colleagues with local experience which certainly trumps our intellect, knowledge and experience nearly every time.  Well not every time.  We have some pretty smart cookies with us, faculty and learners.

But more disconcerting I think is a category of factors, like under-nutrition, which I refer to as “the disease hiding in plain sight.”  We see a tremendous disparity in things we think are controllable in any setting.  The Ob suite is always clean, despite a half-dozen or more deliveries per day.  I am a little reluctant to cast aspersions, since we know that the resources are so frustratingly low.  Some of the wards are dirty.  Yes, it is difficult to keep the chickens out of the open ward.  And some of the wards were painted last year.  This was a donation by visiting group.  Maybe the dirty stains need to be covered by new paint now.  Still, without cleaning, it will need more paint soon.  Does the lack of resources excuse the dirt?  Or perhaps the lack of resources saps the pride from the staff and this has become the “best we can do.”

And here we are.  All bright and shiny, here for a few weeks once a year.  Who are we to criticize?  We want to help and yet we must take great care not to judge.  So our existential question is this: how?

The above is capped off by the importunate speech we heard this morning.  It was mostly in Swahili, but several of us picked up on the words, “palliative care.”  We asked for a summary in English.

The palliative care team is usually a chaplain as leader, a nurse and a doctor.  They go out about once a week if everyone is available.  They dispense some medicines, write prescriptions and provide spiritual as well as medical care, a truly holistic endeavor.

They have no funding.  And they have 850 patients in need, and simply too few staff to provide the care.

Except as the charity of the staff can provide, that is.  They did have some fairly regular support from somewhere which has dwindled.  There is also the “poor patients’” fund, donations solicited from visitors.   I think it is a pittance.

I know the palliative care team could use cash, especially a regular stream.  They write prescriptions but often are thwarted when the patient cannot afford the medicine anyway.  Heart rending was the request for food and clothes and, of course, medicine.  Yes, all of those do translate to money.  And I suppose there is no end to the need.  It is the starfish story.  We will not likely save these humans but with a little cash, we can make them more comfortable.

Tungamalenga and Ruaha

After spending three weeks in Ilula, we trekked our way to Tungamalenga as a quick stop before reaching Ruaha national park. The drive started out smoothly before roughing out into a rather bumpy ride for the rest of our trip. In Tungamalenga, we had the opportunity to meet with Dr. Barnabas, pastor Eva, and others who had been working and living in the area for at least the past five years. Despite the rainy weather, we weren’t deterred from making a trip to the Maasai villages. Sadly, both of our 4x4’s were stuck in the muddy terrain shortly after we began our journey.
We all walked to the first church and were warmly welcomed by the Maasai who sang and danced beautifully for us. On our way out from there, one of our vehicles got stuck in the mud again. We were stuck for quite some time; luckily, the Maasai crew helped us out from the ditch. Despite the rough start, we all had a wonderful time there altogether.

In Ruaha (or Ruvaha, which means “Great” in He-he), we stayed at the bandas in the Mwugasi Safari lodge. Each banda was built next to the river and all were beautifully decorated with ecologically sensitive material.

On the first night of our stay there, we were told that an unfortunate impala was killed by a pride of lion right behind out camp. We didn’t see the leftovers from that incident, but we encountered several lion prides with their kills on our first full safari day. Our tour guides, Festo and Mwarisho, gave us an awesome tour of the park and helped us dig our way out from the ditches when our vehicles got stuck in them. We saw a variety of animals, plants, and birds from our visit and had many great (photo)shots of them for proof. As an added bonus from the rainy weather, some of us also managed to capture an awesome shot of the thunder as well.

From Mwagusi to Minnesota

Jan 27 2016

Kari and I awoke monday morning to the sounds of the African bush in Mwagusi Safari Camp in Ruaha National Park in anticipation of beginning our journey back to Minnesota. The rest of the group had already gone on a morning safari so Kari and I had breakfast with the camp ccordinators and some other guests. One was Carol, who works for the Wilderness Conservation Society on a project in Ruaha: she is studing the vultures which we happened to see the evening before near a lion-kill. Three fun-facts about vultures are: 1) they are very social creatures, 2) the highest recorded ariplane-bird collision was a vulture riding a thermal at 10,000 feet! 3) an expanding vulture population is an indicator of increasing elephant poaching as the vultures feed on the carcasses.

On the ride to the airstrip in Ruaha, we passed a herd of elephants that were only 5-10 yards off the dirt track. The flight to Dar was uneventful, but Dar was warm and muggy--reminded me of our stop over in Dar 3 weeks ago and our trip to USAID and to Kampala International University Medical School (and the visit to the cadaver pit).  We took Phil's suggestion and visited the center-city fish market then found a place by the Indian Ocean to drink cool liquids until time for dinner with Grey Saga and Gloria. It took 90 minutes to get from Sea Cliff to the airport in the chaotic Dar traffic.

The flight from Dar to Amsterdam was uneventful. On the flight from amsterdam to Minneapolis, I ran into a flight-attendant who is also a  patient of mine (breast cancer--an occupational hazard for flight attendants) and Dr Michael Westerhouse and his wife Amy who were returning with students from their Social Medicine course held annually in Uganda.

It was 27 degrees F upon arrival in Minnesota--not too bad for this time of year. It is realy difficult for us that first evening back to stay up much past 6pm so we were in bed early and, of course, were up very early in the morning (2-3am!) As I was driving to Lifetime Fitness at 5am this morning, I saw some remaining holiday lights in the yards of neighbors--nothing more poignantly reminds me of Minnesota in the winter then holiday lights and snow.  One of the yard displays included a familiar message to us Tanzania travellers in little white lights: "Joy to the world."  To this I can only add ..."and joy to you and me."

Randy

Church at Lugala

This post is a little different than most.  John Kvasnicka and I are not with the group.  They are at Ruaha after a night in Tungamalenga where they stayed overnight then attended church this morning.  If they were fortunate, they got to go out to a Maasai village. It has been extremely wet, wetter that any previous January that I remember, which potentially creates famine conditions if the crops are drowned and cannot be replanted.  There is also a high potential for more than usual malaria cases due to standing water.  This circumstance meant they could not take the coaster bus to Ruaha, so they went in two 4x4 vehicles, which could allow travel to the village (fingers crossed for them).  This morning after church at Tungamalenga, the group traveled to Ruaha National Park.  They met Anne Joseph and Phil McGlave who arrived by light plane at Msembe/Ruaha airstrip in the morning.  They should all have enjoyed a great afternoon game drive. In the morning, the group will say farewell to Randy and Kari Hurley who are heading out from the airstrip and on their way home. We will let them tell more as the days unfold rather than my assumptions.

Lugala church

Pastor Gary Langness arrived this morning at the Cathedral to preach only to find he was not on the schedule.  We were all going to listen to him.  Birdie and I are more small church people, at least smaller than the Cathedral, so we did not mind.  We have an Mzungu historian with us in Iringa who is currently teaching at University of Iringa.  He is fluent in Kiswahili and was planning on worshipping at Lugala with a friend, not too far from Iringa and in a very rural area.  Did we want to go there instead?  Sure!

I am guessing you can read another account here: www.mzungucarol.tumblr.com . It was Paul Bjerk, the historian, me, Birdie, John, Carol and Gary and then we picked up Johanna to go out to Lugala.  Once we turned of the paved road, it was an off-road adventure.  Johanna called his friend Philemon at Lugala to warn him there would be more guests than himself and “Paulo.”  The service was to start at 10 AM.  We were about 50 minutes early. Eventually people trickled in and the service started about 10:40 AM.  People continued to trickle in throughout most of the service.  The congregation is about 150 people and perhaps 75 were in attendance.

Inside before service

There was a lot of music.  Since there was no electricity at Lugala, it was a capella with drums accompaniment.  We all loved it!

I am not quite sure how this works, but there were two sermons.  To quote Pastor Langness, the FIRST one was really excellent.  I don’t remember precisely how long the service was.  I think it was nearly 1 PM.  There was time for two collections.  I thought there was to be a third, but if there was I missed it.

We were invited to Philemon’s house for lunch, soda, rice and chicken prepared by Philemon’s beautiful wife, Rhoda.  Yummy!  I am guessing at Rhoda.  Between the rolled R sounds and indistinct L sounds, I cannot be sure.

We visited for a while then took pictures of Rhoda, Philemon and their 4 children.  To get to the house, we had to tramp along a narrow path about a quarter mile, not too easy for Birdie suffering from her hip arthritis.  We tramped back, observing Philemon’s lush fields.  He has cattle for their free fertilizer and the cows also provide milk.  The whole area is beautiful.  There are small mountains on both sides of the valley. As we drove back to the pavement, we passed through the village.  Historian – anthropologist Paul noted the difference in the social environment between the even more rural Lugala and this village.  We all enjoyed the entire trip, arriving home about 3:30 PM.  That is how going to church in rural Tanzania is!

Philemon's Family

John and I head back to Ilula in the morning.  The Ruaha folk will arrive Tuesday evening.  I expect we will head into Iringa for Saturday R&R and I assume we will be regaled by safari stories when the troops return.

Third Annual Ilula Minnesota International Healthcare Conference

Thursday and Friday were devoted to presenting our third annual Ilula Minnesota International HealthCare Conference.  Starting in 2014, Shoulder to Shoulder has presented the annual conference for our colleagues in Tanzania.  All our presenters did a great job and all the healthcare professional teams that attended gave positive feedback and will return to their hospitals with quality improvement plans to implement based on what they learned.

Our first course was presented in January 2014 with 30 attendees.  Based on extremely positive feedback from the initial conference, our partners in Tanzania encouraged us to significantly expand the conference to offer this educational experience to a much larger audience of caregivers.  As a result, we expanded the 2015 conference to include all 28 Southern Zone Lutheran Hospitals and hosted 100 professionals.   From each hospital we invite one doctor, one nurse and one pharmacist.  This year we are also partnering with Global Health Administration Partners to provide education to Hospital Administrators at each hospital.

Our conference is based on 5 principles:

1. Lifelong Learning.  We believe all professionals should contribute to a culture of learning and continuously learn to improve our practice.  We include students and residents in preparation and presentation of the conference.
 2. Interprofessional teamwork.  We include nursing, pharmacy, administrators, and physicians in both the attendance and presentations.  We emphasize teamwork throughout the conference.  We each bring unique knowledge and skills to share; specifically Tanzanian presenters emphasize tropical medicine and HIV, American presenters emphasize the growing global problem of chronic and non-communicable diseases.
3. Mutual Respect.  We emphasize the ability for all our participants to teach and learn from each other, in spite of our differences in practice setting, culture, and socioeconomic situation.  We include local leaders in planning the conference and select topics based on feedback from participants.  Presentations are delivered by both US and Tanzanian professionals.  We adhere to the highest international standards in the preparation of the educational content and accreditation of the program.  The program is based on a foundation of a longstanding and ongoing relationship.
4. Continuous improvement.  Learning should drive improvement in practice.  We include planning sessions for participants to complete planning documents based on learnings to institute improvement plans upon returning to home hospitals.
5. Sustainable Impact.  We believe that education and improvement are some of the most valuable ways to promote a sustainable positive impact on the health of our partners’ communities.

Our conference is accredited by the Education Department at the HealthEast Care System to provide participants with CME credits for participation in this program, and the University of Minnesota International Medical Education and Research Program.

Funding for the course is provided through generous contributions from several foundations and individuals.  All funds raised go entirely to hosting the conference, and support for local Tanzanian staff to attend, including meals, travel and lodging expenses.  We want to thank all our donors including Global Health Ministries, The Peter King Family Foundation, Dale and Patty Anderson, Arlene and Dave Tourville, and others.

The Rainy Season in Tanzania

The rainy season has come early this year to Tanzania.  My guidebook says the typical season starts in March, peaks in April, and ends sometime in May.  Storms here can blow in with nearly no warning sending everyone scrambling for cover or to collect their half dry laundry from the lines.  Our rain buckets and barrels are constantly full, any water we use to wash our clothes or hair is replenished in no time.  The hospital laundry is washed by hand.  Women here soak and scrub the linens then hang them out to dry.  I don’t know when they are finding time lately to finish all their work with the wet weather.  When everything is suitably dry the women take them down from the lines an iron all the sheets then fold them precisely into impossibly small bundles.  I’m sure the local farmers are happy with each new shower but so are the mosquitoes.  Their numbers seem to be on the rise lately.  It can be hard to treat patients with malaria and mosquito borne viruses without a little paranoia creeping in. 

The conference is now over and we are looking forward to an upcoming Safari at Ruaha National Park.  Stay tuned to this blog and your Facebook feed for the flood of pictures that are on the way as surely as more rain.

Changes and No Changes

I have been coming to Ilula since 2006, before it became a hospital when it was still Ilula Lutheran Health Center. The changes since then are visible and palpable! The most visible are the buildings. In 2006, the surgery center was new. Now there also is a new laboratory, a new casualty and x-ray building, a new nursing school with dormitories and cafeteria and guest houses. These buildings we're funded by Shoulder to Shoulder and the Peter King Foundation.

In the same 10 year period, the hospital also built an Internet cafe, converted the old x-ray buildin to serve the new Hypertension and Diabetes clinic and is in the process of rebuilding the private wards to increase revenue and serve more affluent patients.

The palpable differences are in attitude, patient care improvements and staffing. In 2006, the Health Center was staffed by 1 Medical Officer (MD equivalent), 2 AMO (assistant medical officer), and 3 Clinical Officers (equivalent to a nurse practitioner). They did emergency c-sections because it was necessary to save lives. Today there are 4 Medical Officers, 2 AMOs, 5 COs and 3 ACOs (assistant clinical officers). C-sections are routine with approximately 1 per day - yesterday there were 2.

The hospital administrator, who had no specialized training, has now received his masters in hospital administration. The hospital management team is well defined (Medical Director, nurse matron, finance director, chaplain and administrator) and meets weekly to discuss and solve issues. A quality improvement plan has been developed using a government-provided self-assessment tool.

Sanitation and infection control processes have improved, although as in the US, doctors and nurses don't always wash their hands between seeing patients. Under the leadership of Dr. Savelo, the new Medical Director, morbidity and mortality meetings have begun to enable learning from poor patient outcomes. For example, the recent organophosphate poisoning will not soon be forgotten and we suspect the Tanzanian clinical guidelines will be consulted more frequently. It is unknown whether different actions would have saved this individual or not, but it will surely save future patients because organophosphates are a common pesticide used in this largely agricultural region.

Today, as visitors, we have more available to us. Anna, a local restaurant owner, closes her restaurant while we are here and supervises a crew of 4 other women who cook for us and clean the main guest house. We have a remarkable array of food dishes, including an "out of this world" mushroom sauce are with fresh squeezed coconut milk (hand squeezed - not from a can!).

Some things don't change - the kind-hearted people, the beautiful view and cooking over a charcoal fire (even baking a yeast based whole wheat bread is done over charcoal).

********Posted by Cindy Wilke, Director of Global Health Administration Partners***********

19/1/16

This morning Aaron gave a little talk on organophosphate poisoning at morning report. It was a delicate subject because the evening before a patient had died from organophosphate ingestion. However, I think it was well received by the Tanzanian staff. Although they aren't well acquainted with the idea of a morbidity and mortality meeting, I think it was a useful conversation to have. In the US we use M&Ms as a way of internal quality improvement to learn from our mistakes. We hope we can inspire a culture of teaching and continual learning here that will be locally led and sustainable. 

After rounds Hindi, Katie and I prepared to go on mobile reproductive and children's injection rounds at a town about an hour away. Around 930 we packed into the Land Rover used for palliative care and started out on the road to Image. We had a few stops along the way to pick up some nurses as well as some women and children who hitchhiked in the back of the truck with us. After about an hour and a half of driving on the muddy red dirt roads we arrived at the village. We were at the base of the mountain we can see in the distance from our house and the scenery was incredible. Outside there were babies and young children being weighed from a scale hanging from a tree. The babies were put in katangas to be weighed and the small children in overalls. Our injection clinic was held in a small building off the side of a church. The patients came in one by one with their cards listing their previous injection dates. I was surprised that the immunization schedule was very similar to that in the US and most of the babies were well nourished. A couple women came in for depo-provera injections as well. They ranged in age from 20 to 40 and all had other children. Despite the language barrier we learned a lot of Swahili phrases from the nurses running the clinic and were impressed with their efficacy. After a couple hours we packed up our supplies and headed back to drop the nurses off and periodically stopped to drop off the other hitchhikers who were going in the same direction. 

In the afternoon a few of us went back to the hospital to check on a infant who was admitted earlier with severe dehydration and a fever. After examining him we called the clinical officer on call and suggested some medication additions and oxygen to possibly improve the patient's chances of recovery. The only thing we can hope for now is that he makes it through the night. We have to treat most infectious processes here empirically due to our laboratory capabilities. With broad antibiotics, IV fluids, and corticosteroids we hope we are covering most diseases that could be causing the baby's severe condition. 

The evening was consumed with walks and dinner with the hospital administrator, Kikoti, as our guest. Ken Olson also arrived today so we had a full main house. Anna, our cook, made an excellent dinner again and we spent the rest of the night talking about our day and experiences. 

Making Hay While the Sun Shines...or hanging laundry before the torrential downpour

So, it's rainy season. Not to complain, dear subarctic followers, but I have a singular talent for choosing to wash and hang my clothes at the most inopportune times. We typically have showers during the evening and into the morning. The second it's sunny, I beat feet to get everything smelly soaked, scrubbed, and ready for the line, by which time storm clouds typically roll in. Extra rinse cycle, I guess? 

I think something we Ilula Friends try, and sometimes fail, to be cognizant of the legacy we leave here. For the sake of metaphor (and at the risk of sounding conceited) I look at our visit as a burst of sunshine. We arrived energized, ready to make a difference, and were simultaneously overcome by how under-resourced our Tanzanian friends are, and how very much they are able to do with what they have. Everything we see is tainted by our experiences in the American healthcare system, which can build a basis for collaboration and innovative ideas, but can devolve into judgment and despair.

From an administrative standpoint, Cindy, Danny, and I have been daunted and energized by opportunities to improve patient medical recordkeeping and inventory management. It took about a week to gather all of the information necessary to determine our direction: we met with the administrator, CFO, pharmacist/med supply manager, and recordkeeping staff. My moment of shock occurred when we walked into the medical record room to find patient files stored in bookcases to the ceiling, and piles on the floor. The horror! We are working through what it will take to make these processes electronic, and cut down on the ingenious, but time-intensive paper systems.

Something I’ve struggled with personally is finding ways to contribute to making improvements while I am here that will be sustainable into the future. For instance, I’m hoping to reorganize and compile patient records to come up with a searchable master list for medical records staff to use to identify patients. While it will be a time-consuming project, it’s something I can finish in the next three weeks. It gets sticky, however, not being 100% certain that: A. it’s formatted in a way that is useful to staff, and B. they’ll even be willing to abandon the paper register.

Now that we all have some understanding of how the ILHC operates, we’re beginning to decide how to leave our marks - to somehow repay these wonderful people for all they’ve taught us by offering our own unique piece of expertise. It’ll continue to be a struggle to realize that all may seem easy and straightforward while we’re here, but we will largely be absent for the implementation struggles that accompany any change. If we don’t do a good job of designing our programs, it will be very easy for things to stay the way they are. That’s why it’s important to take advantage of the sunshine, but to realize that rain will come.