Steve Becknell

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6/17/2010
Steve Becknell, Former field technical assistant in northern Ghana and then resident technical assistant in southern Sudan

Guinea Worm Oral History Project - Interviewed by Nancy Hilyer

Source

The Carter Center Office of Public Information, Health Programs
453 Freedom Parkway, Atlanta, GA 30307
www.cartercenter.org

Citation

“Steve Becknell,” The Global Health Chronicles, accessed March 30, 2017, http://globalhealthchronicles.org/items/show/4743.

Guinea Worm Oral History Project - Global Health Chronicles

Interviewed by Nancy Hilyer, June 17, 2010

Steve Becknell- Former field technical assistant in northern Ghana and then resident technical assistant in Southern Sudan

(0:00)
NH: This is an interview with Steven Becknell, formerly a field technical assistant in northern Ghana and then resident technical assistant in southern Sudan.

(0:23)
NH: This interview is being conducted in Atlanta on Thursday, June 17, 2010. The interviewer is Nancy Hilyer. To begin with, I want to thank you on behalf of Dr. David J. Sencer, who initiated this project to document oral histories from persons who have been instrumental in eradicating Guinea worm from the world. You are one of those persons. Will you please state your full name and state for the record that you know this interview is being recorded, Steve.

(0:49)
SB: My name is Steven Becknell, and I know this interview is being recorded.

(0:52)
NH: And will you state for the record your contact information, like a telephone number or email that you have right now.

1:00)
SB: OK, my phone number is 404 520 8974, and my email address is s_becknell@yahoo.com. B-e-c-k-n-e-l-l.

NH: Great. OK, to begin with, can you tell us something about your early life, where you were born, what size family you grew up in, your early childhood years?

(1:27)
SB: I was born in Lochmuehle, Germany. My father was in the US military, stationed there at the time. We moved to Columbus, Ohio, when I was two; and I lived in Columbus, Ohio, and grew up there. I have a brother and a sister, and my parents are still alive; they're in Columbus, Ohio, now.

(1:49)
NH: So what sort of childhood did you have there? From two until elementary school, what was life like?

SB: Pretty normal, suburban kid lifestyle, you know, played soccer and played outside a lot. I liked to read books. I started going to a private all-boys school in fourth grade, and then it went co-ed in ninth grade, and I finished there. So from fourth grade through high school I went to a private school. From kindergarten through third grade I went to a public school. And then I got a scholarship to study at Emory University.

(2:32)
NH: What subjects in high school- were there, ..any particular direction, or just general liberal arts?

SB: I liked, I mean, the courses I enjoyed were more history and writing.

NH: Liberal arts, as opposed to the sciences?

SB: Yeah, you could say that.

NH: Interesting.
(2:52)
NH: OK, formal education: straight to Emory out of high school?

SB: Yeah, I had a scholarship to study at Emory University, and then I finished undergrad and studied political science and philosophy.

NH: In undergrad, was political science and philosophy, OK?

SB: Yes.

(3:12)
NH: Then for grad, you went to, didn't you go to a school of public health?

SB: Yeah, after undergrad I went directly to the school of public health. Before that though, I spent a semester studying abroad in Kenya, at which time I had an internship with CARE International with the Child Survival Program that they had in western Kenya. And that was a very instructive experience for me. And I had already applied to the school of public health, and so this kind of confirmed that I wanted to be involved in global health.

(3:51)
NH: Now what took you to Kenya, I mean, how did you..?

SB: I had two credit hours left, and I had basically an opportunity to go to Kenya for free because of the scholarship. So I figured better make use of it in Kenya than to waste my time.

NH: And you were there for one year?

SB: With two credit hours in college - just one semester, six months.

(4:10)
NH: Six months, in Kenya, okay. So that sort of confirmed that. Now, you graduate from Emory, graduate from the school of public health, directly into The Carter Center, or CDC, or?

SB: Pretty much, you know I was in the Master's Internationals program at the school of public health, which basically requires a commitment into Peace Corps directly afterwards. In 2001 I slipped a disc in my back and I was not able to join Peace Corps. And they wouldn't let me for medical reasons take my assignment, which was to be in Mauritania. So there was a period of about, let me see here, May, June, July, about three months where I was unemployed. I was still trying to rehabilitate my back and get to more of a stable condition with that, and then, while applying for jobs. And then this came up.

(5:12)
NH: And you went with your slipped disc to the field?

SB: That's right, yeah.

NH: So The Carter Center is not as…

SB: If the Peace Corps wouldn't take me, The Carter Center would, go figure.

(5:22)
NH: So you did get hired by The Carter Center at that point, when your back was in better shape, okay?

SB: Yeah, I mean, somewhat better shape.

NH: Okay, so what was your first assignment with The Carter Center, with your slipped disc?

(5:37)
SB: I worked in northern Ghana, in a district called Nanumba, starting in August 2002. And I was a technical advisor, technical assistant, to the program there, working with the district health services and the team out there.

(5:58)
NH: You were working out of Tamale?

SB: No, out of a town called Bimbilla.

NH: Out of Bimbilla. And what were the circumstances there? What were the Guinea worm cases, what was your living circumstance?

(6:10)
SB: Nanumba District, as I recall, was the most endemic district in the country in 2002. It was like first or second, they were always competing with East Gonja. So there were a lot of cases. We knew pretty much where transmission was happening. We had some surprises going into the next transmission season, but I think the situation that I found was that basically there were no full-time workers in the program. Everyone was tasked with other roles and responsibilities. So I think like the first step that we took, as I recall, was really to just sort of verticalize the program, and have full-time field workers engaged who could dedicate themselves and have functional motorcycles, and them being paid an adequate salary. And we worked through all that.

(7:03)
NH: What was your first year in Ghana? Your first?

SB: 2002. August 2002 was when I started.

(7:14)
NH: That was when you were first there, okay, and you’re living?

SB: Right, when Elvin was there too. I mean, Elvin was the regional technical advisor at the time.

NH: I thought it was earlier than that.

SB: No, no no, we came in right-

NH: No, definitely 2002?

SB: Like maybe a week after he arrived, yeah.

(7:33)
NH: Okay, so you were living in Bimbilla, were you living in Bimbilla? OK, and what was your living circumstance there?

SB: Well, it was interesting. There were like these guest quarters sort of on the outskirts of town. I stayed out there. My driver had a room, and I had a room, and we just crashed out there. Yeah, we, you know, there wasn't any electricity or anything.

NH: Clean water?

SB: There was a well. Boreholes nearby. We had to fetch water in a jerry can and bring it.

(8:10)
NH: It was basically just you and the driver?

SB: Yeah, yeah, cause there were only two rooms in the whole facility. So yeah, just me and the driver.

(8:20)
NH: Okay, and you had no residence in Tamale at that time?

SB: No.

NH: Okay, just in Bimbilla?

SB: Yeah.

(8:25)
NH: How long were you resident there?

SB: For about a year, and then I transferred over to be – I still worked in Bimbilla and in Nanumba District a little bit, but then I transferred over to another district called Nkwanta, which then became the most endemic district in 2003. So, basically, you know, these districts become one becoming more endemic than another. A lot of it I think is a function of poor surveillance to begin with and, you know, not really knowing what the full burden of disease was in the country. And as, you know, we - there was a group of us that came out in 2002 full-time working as resident, as technical advisors to the program, whereas before, the technical advisors were only part-time, They were only there during transmission season. So, you know, getting continuity and getting probably the full picture of the disease profile in Ghana was a little bit difficult in those circumstances.

(9:15)
NH: Okay, who were those people with you, the grouping?

SB: Of the expatriate technical advisors?

NH: Yes, yes expatriate.

SB: Cause I worked with a very good national technical assistant named Robert Agoe in Nanumba as well. We went out there as a team.

NH: You want to spell his last name?

SB: A-g-o-e.

NH: A G O E.

(9:34)
SB: Yeah, Robert. He's still with the program in Ghana, I believe. He's one of the senior advisors to the program. But the other expatriate consultants at the time were another guy named Jim Albertson and a lady name Adrianne Siebert. And I'm trying to think if there was anyone else out there at the time.
(9:58)

NH: Now, were you living together, or were you living in the same area; were you in different areas?

SB: No, different areas, different districts. We saw each other maybe once a month for a meeting. Sometimes we'd pass on a road.

(10:12)
NH: But it was good coordination among you?

SB: No, cause there's no way to communicate. The phone system- there's only one phone in the entire district. And that was at a calling center, and sometimes it didn't work. But I had decent communication with Elvin back in Tamale.

NH: And they did too, I would assume?

SB: Yeah, because he had a phone at his hotel room. And also he had a phone in the office in Tamale.

(10:39)
NH: So that was the coordination?

SB: Yeah, yeah, back to center in Tamale.

NH: In Tamale.

SB: And with Nwando Diallo, who was the resident, the resident advisor -

NH: In Accra.

SB: In Accra, yeah.

(10:53)
NH: Well, what was the situation- when you first arrived in Ghana did you have any sense of the numbers of Guinea worm?

SB: Well, I mean they gave us a bunch of line lists from the previous consultants. I mean, Ghana had its reported figures. My sense of things after just having visited a few communities, was that cases were being missed, and not all villages were under surveillance that needed to be. So I felt there was underreporting, and, sure enough, there was, I mean, - as we saw in the next transmission season. Surveillance just wasn't active. I mean, it was good for a control program, but I think we, you know, over the course of those years we really tried to make an effort to kick it into high gear. And even then there were gaps, because we didn't have, you know, enough people, or enough of the full picture. So whenever you have those gaps you have surprises, and Guinea worm is rather unforgiving that way.

(11:54)
NH: Sure.

SB: So, I mean, we had an idea of the extent, but certainly not the full extent. Because we discovered a very big – I hesitate to say it's an outbreak, because I think the cases were there the year before-

NH: You're talking about Volta?

SB: But in Volta Region, in Nkwanta District - yeah, we discovered that in a case we mobilized a mass case search over the course of three days before the annual review meeting in March 2003, and we just took motorcycles around.

(12:23)
NH: Okay, March 2003, I'm going to get back to the Volta question, because I know that you actually came up with that. Someone came into the district, and someone came to your containment center? Is that right, containment center?

SB: Well, we kept getting cases coming to the case containment center. And people would tell us, well, come visit our village. And we said, well, you know it's not even the same region, let alone the same district. And protocol in Ghana was pretty thick at the time. And certainly we had our hands full as it was, in our own district. And we kept notifying the Volta authorities and telling them, you guys need to come investigate, you need to do something.

(12:58)
NH: Did we, did Carter Center have anybody in Volta, at the time?

SB: No, no, no, there was- the Ministry of Health did; the Ghana Health Services had a coordinator. And you know, for whatever reason, the Volta Regional Health Services and the Nkwanta District Health Services, despite our repeated efforts to notify them by phone, refused to visit those communities. So we kept getting cases coming to the case containment center. So we figured, well we're just going to go visit a few villages. So a guy named Joe Lahr who was one of the regional -

(13:34)
NH: Local regional-

SB: Yeah, he's Ghanaian, worked for Ghana Health Services in the Northern Region. He came out with me, because there were a lot of, we suspected that there was going to be a lot of severe infections. And there were. And so we just spent days in just two villages along the border with Nanumba District just, you know, looking for cases, managing them, treating the water, giving out filters. But then we just realized that there's much bigger problem than just these two villages. So that's when I basically just took everyone from my district and we moved with our tents and mosquito nets and set up shop in Nkwanta District for three days and covered all the villages.

(14:20)
NH: With education and filters - is that what you're talking about by covering all the villages?

SB: No no, we did a case search. We identified where all the villages were. We drew maps of the district, and we just got, you know, a quick snapshot. We didn't even have enough case management materials. We would've needed like probably several trucks. We didn't have the filters in-country even to supply Nkwanta District. But we did the best we could to determine what was the extent of the problem. We figured the water had already been contaminated, given that it was March, and transmission season begins in November, and that we were going to see a lot of cases in 2003 transmission season going into 2004. So the idea was, let's at least figure out the denominator of villages that need to be captured under active surveillance, and zone the district properly, and we'll hire and train people and get village-based surveillance up and running. So that was the intent of that, those three days, was just to determine the extent of the problem, mobilize resources at the national level, ..

NH: So you could do something.

SB: ..bring attention to the problems in Volta Region. And Volta Region was claiming that they broke transmission, so, you know they're reporting zeros at their meetings. But on the other hand, they have the most cases in the entire country. So you know, there was some anxiety, and folks bent out of shape by that, but..


(15:41)
NH: Some folks, you’re talking about local folks, you’re talking about the health-

SB: Certainly, I think there were people at The Carter Center who were disappointed by the outcome as well, on a technical level. And then there were those who really did not want to be exposed, who were also very angry that this mission had been conducted. We did go through the protocol of informing the district director of health services and informing the regional coordinator, and even invited them with us. But there was no support from the district and no support from the region at the time. And you know, over time, you know, working with the district director of health services, we were able to make a good relationship, really move quickly to break transmission.

(16:23)
NH: That was my question, how did you feel about local support at that point?

SB: Well Nkwanta District is an impoverished district to begin with. And, to be fair, I think that the district director there at the time - and he's currently in a senior leadership position in the Ministry of Health - is a true innovator, and a, well, what I would - I think he's an excellent public health practitioner. I think he's got some projects, he piloted this community health planning services strategy in Nkwanta District. And this is a guy who built the district from the bottom up with his hands.

NH: What is his name?

(17:00)
SB: His name is Dr. J. Awoonor-Williams, he goes by the name Koku, that's his common Ghanaian name. This is a very dedicated guy.

NH: Dr. Korkor? You're not talking about Dr. Korkor?

SB: No, that's Dr. Seidu.

NH: Dr. Seidu, yeah, okay.

(17:19)
SB: Someone different. He, this doctor I'm talking about, you know he built the hospital from scratch. He pioneered the extension of health services through this community health planning services program, really brought up immunization coverage, access to maternal child health.

NH: Okay, so he's an innovator, was he interested in Guinea worm eradication?

SB: I think, you know, to the extent that he recognized it as a problem in his district, yes, I think he was supportive - and definitely did not tie our hands. Did he have competing priorities? Yes, many, many competing priorities, you know, I think we find this in a lot of countries. This is not a disease that kills people, so it's always a balance there. And so you have to figure out, well, where, where can we expect support that's reasonable, and where do we just need to be at least given permission to do good work.

(18:07)
NH: Okay, but when you say people's noses were bent out of shape, who are you talking about? Are you talking about local people? You talking about The Carter Center's nose was bent out of shape?

SB: Oh, I think some of the authorities were embarrassed.

NH: Authorities- local authorities?

(18:19)
SB: Yeah, yeah, and to a degree even, I would imagine that at the time, as much as it was, I think, appreciated by some of those authorities eventually, I think they were surprised. And no one likes to be embarrassed in a national forum. And though that was not the intention of doing the case search and presenting the findings, that's ultimately what happened, is that people were embarrassed.

NH: Okay, where were you living at this point now when you were working in Volta or when you found these cases that came out of Volta? You were working out of Tamale at that point?

(18:55)
SB: Bimbilla. I never worked out of Tamale until 2004.

NH: But you were living in Tamale?

SB: No no, I lived in Bimbilla.

NH: Well, when we were there you were living in Tamale.

SB: No, I lived in Bimbilla from 2002 until 2003, about April 2003 - I lived in Bimbilla. And then from April 2003 until roughly Elvin's departure from the country, so roughly April 2004, yeah, 'cause I left, I left Nkwanta after March 2004 because that was the end of transmission season. So say April 2004 I lived in a town called Pasa, and Pasa had a health center where I stayed in the nurses' quarters. Now once in awhile we would come to Tamale for meetings at the regional level. But that was once a month, maybe once every two months. During transmission season in Nkwanta District I just stayed out there for three months straight, and just didn't want to bother with having to come back to Tamale.

(20:13)
NH: Okay, what was your family situation at that point? Did you- you met Ann there? Your future wife?

SB: Yeah, I met my current wife in Ghana. We didn't start dating until late, later, like probably, I guess, March 2004, yeah

NH: Okay, so you met your future wife; that's pretty interesting, I think, for people to know.

SB: But we were good friends from 2002 on.

NH: And she was with the Peace Corps?

SB: She was with Peace Corps as a volunteer, and then in 2003 she also became a technical assistant for The Carter Center, but working throughout the country and primarily on health education and trying to improve the quality of surveillance in areas that had been thought to be free of Guinea worm disease but really were not. So she also uncovered a few of these surprises as well - in Afram Plains and western region and the northwest and area around the upper west.

(21:17)
NH: Okay, didn't you organize the building of case containment centers in Ghana? Wasn't that a major part of your-

SB: Yeah, we did a couple. Yeah, you know, I have the feeling that they had less affect than the actual process of building them. Because by building them you had to be in the communities constantly. And whenever you're in the communities constantly you're also always doing health education and looking for cases and teaching people how to filter. So I think it made a difference in terms of building some rapport and trust with the communities. It's interesting, you know, in Nanumba District we used case containment centers and, you know, there was a reduction, there was a sizable reduction that year. I think it was over like 60% between 2003 transmission season and 2004. But when we didn't do case containment centers in Nkwanta District, mainly because the scope of the problem was so large. and I said I don't want to do them. You know, I really, I mean, I said I don't even want to work here if we're going to do case containment centers. Cause I really felt like it was a distraction and that the bread and butter of the program is good surveillance, and then you get your health education in, get some good vector control, and filters are going to help a lot as well. Yeah, so we really just concentrated on the communities and really identifying our water sources in Nkwanta, and I think we had over 90% reduction between the 2003-2004 transmission season and the 2004-2005.

(22:57)
NH: But Elvin said you actually were very successful in getting these containment centers up and going with local help that you garnered.

SB: Well, we got ‘em built and, yeah, they were - I'd be curious how one of them is being used now. That one was a permanent structure, and I'd be interested to see if its-

NH: He said you had people out there, you had chiefs out making bricks-

SB: Yeah, but like I said, that's where the value was added, was it's not so much the center itself as an intervention, but it’s the process of building trust with the community. We had an excellent relationship with that community. That was the most endemic community in the district at the time, maybe even in the world, at least by the data that was available globally. I think it was maybe the most endemic in the world. it was called Gbungbaliga. And you know, we had a big party to celebrate the opening of it, and, but, I mean-

(23:56)
NH: Is that the reason you had such good relations, is that one of the major reasons you had such good relationships in that area? Building something together and - is that possible?

SB: I think the reason is we'd just, we’d go and spend nights there. We'd go spend nights in the villages and, you know, we’d try and organize some sort of local celebration. I don't know, I feel like the good relationships are not because of giving something, like something like an object. It's more because you show-

NH: It was building, building something together.

(24:32)
SB: Well, yeah, that's an important activity. I'm not trying to downplay that, but I think that going into a community and showing respect and humility, and eating the food that they eat, and by providing a service that they want to have, and especially advocating for them to receive safe water. And luckily, in both Nkwanta and Nanumba Districts, we were able to get safe water delivery into our top endemic villages during the very exact transmission seasons within, within the time I was working there, when there was really a lot of cases. So you had this really nice synergy between the activation of community-based surveillance, the activities of the volunteers and their supervisors, the delivery of the routine interventions, and then on top of that, safe water facilities coming in. And that just locks everything down.

(25:27)
NH: Was that UNICEF? Were you working with UNICEF at that particular?

SB: No, I mean, maybe it was the UNICEF's funding. There was just an excellent district water and sanitation officer in Nanumba District named Prosper Ahalavore. And he just really cared about the program, like he just thought it was a good program, it was a good thing to do. He wasn't- you know, he was just really a good guy, you know. He would say these borehole are coming into Nanumba District, where are the endemic villages? So always top priority went to the endemic villages. And he just had, you know, he was able to navigate sort of the political sensitivities of safe water development in rural Ghana so that, you know, the politicians were kept happy, but also even the Guinea worm endemic villages got some, got some borehole. And we also, you know, something that we did in Nanumba and in Nkwanta which I felt was successful, is that we did at times hire a mechanic and fix borehole. I mean, I can't tell you how many communities we went to where there's cases of Guinea worm, there's a broken borehole that needs maybe $25 worth of repairs, and, you know, sometimes we were able to get the community to contribute. Maybe it would just be paying the mechanic for his labor, and maybe we'd have to pay for the part. That was typically the arrangement that worked the best, and that way they're contributing something, we're contributing something, everyone's happy, and then there's some sense of ownership on the part of the community. And, you know, over time you also encourage them to develop water and sanitation committees and to open bank accounts and contribute regularly to those bank accounts. And some do a good job and some don't, you know. Every village has its own relationships and politics; that's what makes it fun. It's not a, it’s not a perfect situation, but, you know, nothing is.

(27:30)
NH: What about the Red Cross? How- what role did they play?

SB: I think as a program, it was- I think it's a great idea, if we're thinking of Red Cross in terms of the contribution of getting more women involved in the program, excellent idea. Did it need to be done through a third party? Probably not. And I would even suggest for South Sudan and other endemic countries that they explore ways to get women directly involved, and it has to be. It's a tedious balance with some of the cultural considerations in a country. And certainly there were barriers to women being involved, and, in Ghana and certainly in the experience in Sudan. But there's great value to that. I really do find that you actually get a lot more traction working with women in a community than you do the men, typically. And I think this is a lot the function of working in rural, some of these rural areas where there is a lot of alcoholism. There are- there is asymmetric burden of responsibility on women for household chores and raising their children and doing the farming. And that puts them at a lot more risk. And they're also putting others at risk because when they fetch water and they don't filter it, then you can have a transmission event right there. So, but the Ghana Red Cross Society I think is perhaps, you know - knowing what I know now, if it were to be done again, and I think you really have to look at the strength of an implementing partner organization and if they have the administrative capabilities to handle these type of funds and to manage a program. And clearly Ghana Red Cross Society didn't have that management capability. Most things in Ghana were a management problem. Most things with Guinea worm eradication are a management problem. The science is pretty easy, but how we zone and map out bite-sized areas of coverage- which is a continual process I think in any eradication effort- is one of the critical challenges. And looking at what is an appropriate distance and workload for a volunteer, for this part-time supervisor, for this full-time supervisor. And if everyone has their bite-sized chunk and is properly resourced and supervised, the cases will drop; because this is pretty- it goes away quickly when you got a good plan that you can execute.

(30:16)
NH: Think management is everything?

SB: Yes.

NH: Management and education. What was your- what would you consider to be your major challenge? You and the other colleagues, your other colleagues in Ghana, what was your number 1- did you have a number 1 major challenge?

(30:34)
SB: Oh I don't know, thinking here. Well it certainly was not the communities, that was pretty easy. I mean, you know, I mean, sure there's always challenges, but I always felt like, you know, we were very well received, we were treated very hospitably. We were, I felt like with the exception of a few straggling communities, very cooperative with the program, never gave any of the volunteers any problems- you'd see communities weeding and gardening for volunteers while they were volunteers. You'd see them provide a contribution of yams or even, excuse me, livestock to the volunteers in token of appreciation. There was a real sense of I think gratitude in the districts where we worked. I think maybe challenges were, and I imagine those dealing at the regional and national level faced this even probably more than we did, was, you know, having- setting up a vertical program, because the way in which the program was functioning up until 2002 was primarily as a control program, and that just was not getting the job done. And by that I mean, just even the financial system of getting advances- field advances out- getting rectifications in, having routine meetings at the national level, having standardization of use of definitions of the program, and I think Elvin did a lot of work with this which is really wonderful, using- making requisitions for supplies properly, having supplies available at the proper time for transmission season. But these were larger issues and, you know, when you're operating on a district level you're just kinda like, well, give me what I need to do my job and then I'm gonna do it, and it's actually quite, I don't know, I found it to be quite simple. Not simple, but like in comparison with the experience in South Sudan, it was really, really simple, yeah.

(32:56)
NH: Do you feel like you had good support?

SB: Yeah.

NH: From The Carter Center?

SB: Yeah, yeah, I think so.
NH: You had good support?

SB: You know, I felt like Nwando Diallo and Elvin Hilyer really trusted me a lot. You know, I said when I go into transmission season in Nkwanta, I'm just going to stay out there, give me my budget for three months and then I'll report back to you, and I'm going to do good things. And they trusted me to do that. And you know, I felt like that was very empowering that they trusted me. And I said, you can come visit whenever you like, and they did, and you know we'll look at the problems together because there will be problems. But, you know, I enjoyed the management style of The Carter Center a great deal, and I tried to do the same in South Sudan, I feel like I had to in South Sudan, because the place was so big, and we had such little ability to support technical assistance in the field in Southern Sudan that you know we really had to empower them as much as possible and just trust them.

(33:58)
NH: So you took that to South Sudan, that style of management?

SB: Yeah, and then, you know, you get burned for it at times. People disappoint you, and, you know, certainly the worst case scenario is you end up having corruption even., But I think all in all it makes the program move forward, and there is a sense of urgency with Guinea worm eradication. You know, I'm sure there's challenges that I'm forgetting, I don't know, I tend to remember the good things more than the bad, so, if I think of something, it'll come to mind...

(34:33)
NH: Come back to it? You were very successful in organizing and motivating local people. Why were you so successful?

SB: Well I, you know, I don't know if there's a single reason why- I guess I felt like I wasn't always successful. In fact, I know I wasn't. I think it's a balance And I think any manager or leader or person in that capacity finds you have to have a balance between, you know, establishing that there will be high expectations, that non-performers will be supervised closely to perform better, and that if they don't perform better they will leave the program, that it depends heavily on teamwork, and that we're going to have fun. And I try to concentrate on the fun aspect, because I feel like, you know, if people are well-fed and, you know, everybody gets a Coke at the end of the day and, you know, God knows like at the end of the hot day in Ghana or South Sudan, I definitely wanted something cold to drink. You know, you all try to take care of each other as a team, and I think, you know, we'd go and do these overnight health education activities in communities. We tried to make, we tried to do a lot of fun stuff with health education, and I think people really got into that, you know. We'd do dramas, we'd do a drama and a football match with the bordering villages in Togo, and we would collaborate with the Togolese on that. So you do those kind of things, and especially you do them during the dry season, when things are- I'm sorry, during the rainy season, in Ghana at least, because that's when there are not cases of Guinea worm, or at least not nearly as many. So just try to have fun, I think, with health education. Promoting behavior change is, it's a way of, you know, establishing rapport with communities.

(36:33)
NH: And I guess, living there, as you said earlier, living there among people.

SB: Yeah. Or it's like, you know, some days you're like, okay let's get a goat, or let's go get some fish. And we're gonna go slaughter a goat, and we'll have the goat together, and we can tell funny stories and play some football, or, you know, yeah. I think it's just, living there helps a lot, working side by side with people, showing that you're willing to load a truck together with them, willing to get your hands dirty. I think that's appreciated anywhere in the world though, that humility and, you know, admitting that you're wrong sometimes to people that you're working with or supervising.

(37:13)
NH: Steve, what do you see as your major accomplishment in Ghana? How do you look back, what do you see?

SB: I think my major accomplishment was probably, well, maybe two levels, one of the things that I appreciate the most about this program is that it is very hands-on, and you can see individuals improve a lot. And that's important, it's important I think to focus on that, individual people and individual communities. You can see behavior change in a community I think with this program pretty quickly. And it's- you have to look for certain subtle indicators, for instance, a pipe filter being left hanging on a Guinea worm prevention sign next to a pond. And it's there throughout the entire transmission season. That's usually a pretty good sign that everyone in that community is on board with the idea of this pipe filter is for anyone to use, who's passing through, so that they can have a drink of water safely, and then that person's going to leave it there. And the fact that you can go to that pond time and time again and see that pipe filter there, or maybe someone took it but then someone immediately replaced it. And then, you know, looking for subtle signs like that, you can see changes in attitudes and behaviors in communities. And I think that's very gratifying, because if you wait until your actual reductions, I mean, it may take two years sometimes. Because if you catch it late then you're just trying to get things in place for a lot of cases the next year, and then finally the next year. After that, then you might see a reduction. So I kinda feel like you really have to time it properly to get a reduction within twelve months, really just have to be totally on your game. And in South Sudan I'd even say it probably takes three years to get a reduction, in some of these places.

(39:13)
NH: Okay, any stories you have in Ghana in particular that you happen to remember, happen to recall, of particular interest? Were you ever in a risky situation in Ghana?

(39:34)
SB: Not that I recall.

NH: You're always in a risky situation on the roads, I know.

SB: Yeah, it all depends, like risk- I mean, you know, motorcycles, and there are snakes, and there are things like that. But no, not so much. You know, we really had a nice team. You know, we had some communities where you had to walk to, but that would be, that'd be fun. But I didn't feel like it was risky, I mean, certainly you had a good workout, and you were challenged by it. But, I don't know, other stories? We, when I did work at the central level in Tamale from roughly the time of Elvin Hilyer's departure in, I think it was May 2004, and December 2004 when Ann and I left Ghana for good, you know, I was working in Tamale at the central level, and we had started up this effort to really tackle these large dams in the districts north of Tamale. And so we got some boats; Ernesto helped us get some boats. And I remember that being- you know, it'd take a full day to do some of these dams. It was just ridiculous, you know. You'd have like 300 yards of rope that you were working with, and you would have to get like 12 people even just to finish in like a day with several boats And there are crocodiles in these dams.

(40:56)
NH: Explain what you're doing though, what you're doing at the dam,

SB: Well you're doing, you're basically taking an average of lengths, widths, and depths to get an approximate volume of the water source, which will tell you how much larvacide to apply to the water source. So, we- you know, it's a system of averages based on taking multiple calculations. So you basically construct an imaginary grid over the water source and take in measurements at those different points along that grid.

(41:27)
NH: And this is critical? You don't want too much in there, you don't want too much ABATE?

SB: Yeah, it needs to be measured properly. It's very time consuming. We had whole days where we'd just spend days just in a streambed, walking along, treating the different ponds because in Nkwanta and in Nanumba we had more streams than we had dams. But it ended up being, you know, you'd just target like three or four of these streams and that's- those are the sources of transmission, that's it. So, you know, we'd basically had a cycle each month where maybe one week of that month, that's all you do. You just treat water nonstop. But then the rest of the month you can have more fun, you can do a bunch more health education activities Volunteers are all active in the communities. You know, so I think ABATE is, was a very successful intervention for us in the areas where I worked.

(42:26)
NH: People were not concerned about their cattle, or about the taste of the water, or-

SB: Oh yeah, people were always concerned. But you have to give good education and brief the communities beforehand and even involve them in the process. And we did. We had them help us measure and treat the water sources. So we always got them involved in all of that. But I think that the thing that I am most proud about probably in Ghana was the work that we did in Nkwanta District, because we really turned it around pretty quickly. I think we went from over 1,500 cases to under 200 cases in the course of that transmission season, between March 2003 and March 2004.

(43:17)
NH: That was a major, truly major accomplishment.

SB: Yeah, well, actually I'm sorry, it would be more the comparison of that year with the next year, 2004-2005, and that's where we had the change of cases, because we didn't even discover that it was a problem until March 2003. But that, yeah, that's the accomplishment I feel best about.

(43:40)
NH: It was pretty dramatic; it was a pretty dramatic accomplishment actually.

SB: But it just goes to show that if you really - and we were very fortunate, we had all the stars aligned properly- it was a pretty manageable area. Like you could take a motorcycle anywhere in that area that we were covering and do a site visit in a day, and you could get back to where we were staying in Pasa. It might be a bit of a stretch, you might want to spend at least one night out. But the distances were very reasonable to cover. And that's a luxury when you compare it with a place like Southern Sudan. So I felt like it was, yeah, a lot of cases, a lot of endemic villages, but pretty manageable distances, and the water sources were well defined. And these were fixed communities; there wasn't so much movement except to markets. But, I mean, things were pretty easy.

(44:28)
NH: Easy in hindsight, after being in South Sudan?

SB: Yeah, yeah, much easier than South Sudan.

(44:34)
NH: Okay, you left Ghana.

SB: Yes.

NH: And where did you go? You didn't go directly to South Sudan, did you?

SB: No, I worked for the Centers for Disease Control and Prevention for eight months, primarily on projects in Central Asia.

(44:52)
NH: And what brought you back to The Carter Center?

SB: Well you know, I'd always try to keep a good relationship with The Carter Center. I mean, I had a wonderful experience, and I attended the Guinea worm review meetings. They invited me, and I would try to attend those. And I had lunch with Ernesto once in awhile. And I was aware of the position in Sudan; I applied for it, and I got the job. I'd always wanted to work in Sudan since like 2001. I wrote a paper actually with The Carter Center for part of my MPH program on the, sort of the politics surrounding water development in the Nile River Basin. And I learned a lot about Southern Sudan with that more of an academic pursuit, and I kinda got fascinated with the place. So I always wanted to go to South Sudan. Even when I was in Ghana I was like, maybe I'll end up working in South Sudan would be nice; I like the idea of having that challenge.

(45:48)
NH: So that position came up, and you took it as Resident Technical Advisor?

SB: Yes.

NH: in South Sudan. It was an area existing in an uneasy peace with the government in Khartoum, and how did that- how did you juggle that sort of sensitive situation?

(46:11)
SB: Stay out of it.

NH: Stay out of the politics?

SB: Yeah. I felt like I was assigned to South Sudan, and not assigned to Northern Sudan, not really interested in the politics. I mean, I'm interested personally, but for my job, it's not, that's not why I'm there.

NH: You stayed focused.

SB: I'm there to end transmission in South Sudan, and that's it,

NH: Stayed with that focus.

SB: And, you know, we'll let the northern states take care of themselves. And they did. They had already broken transmission a long time ago.

NH: For the north?

SB: Yeah.

(46:36)
NH: But you still had to work with the North, did you not? You didn't have to work with Dr. Nabil?

SB: Not really, no

NH: Not at all?

SB: No, not from a functional standpoint. I mean, we were happy to; it's just, you know, taking our cues from our colleagues in the Ministry of Health, Government of Southern Sudan. They had for nothing to do with the northern states. It's not personal, and, you know, I think it took a long time for people here in Atlanta to realize that it's nothing personal. No one has anything, in the South, no one has anything against Dr. Nabil. And likewise I never really felt like, you know, Dr. Nabil - I don't know Dr. Nabil very well - but I never really felt like he had any problem with anyone in the South.

(47:12)
NH: No, he'd worked in South Sudan himself.

SB: Yeah, of course, during the war he did. So it's not personal but it is a function of the politics. And there were a lot of sensitivities with that among different members of the government of Southern Sudan, especially in the higher levels of the leadership in the Ministry of Health, to the point where you mention the word Khartoum or the North, and people would go into a seething rage. So, you know, you learn to pick your battles pretty quickly, especially given that Sudan had a lot of battles to fight for Guinea worm eradication. And I felt like getting involved in this stuff, that's just not of interest to me.

(47:53)
NH: Okay, so you walk in as Resident Technical Advisor. Were you taking over for someone? Who was right, was there someone before you?
SB: A lady named Glenna Snyder was the Resident Technical Advisor before me, and so we had a hand over about a few weeks.

NH: Glenna Snyder?

SB: Yeah.

NH: Okay, and who was there when you got there? Who else, was there anyone else, any other colleagues from The Carter Center there?

(48:18)
SB: There was one other field assistant named- I think they call them field assistants or field op- I forget what The Carter Center designation was for this person- but this was a coordinator up in Lokichokio. Her name was Lisa Breed. She was there at the time, but also on her way out, and so was Glenna. And then we had a guy who had been hired to be the trachoma control officer, also based in Lokichokio, a cleaner, a driver, a logistics person, and then the operations manager. So there was a total of like, what, 5 or 6 people when we got there, and 2 of them were on their way out.

(48:55)
NH: And the other three were local?

SB: All of the rest were local.

NH: Everybody was local. You were there without any other Carter, expatriates from The Carter Center?

(49:04)
SB: Yeah, yeah, after Lisa and Glenna left, yeah I was the only one there.

NH: Okay, and so who was your main colleague?

SB: Oh, Makoy, Samuel Makoy from the Ministry of Health.

NH: Samuel Makoy.

SB: Yeah. So we designed the system for eradication of the program, the surveillance system and the forms that we wanted to use. And we just basically adapted the forms from Ghana and looked at the forms from South Sudan.

(49:31)
NH: But you and he sat down and worked up developing a strategy.

SB: Yeah.

NH: for South Sudan?

SB: Yeah, yeah, and based on some of the agreed-to principles even before I joined the program again. And that was that you started with four focal areas in Southern Sudan. One is in Jonglei state, the other was in Warab, the third was in Eastern Equatoria state, and the last one was in a state- well actually it was technically two states, but two counties that bordered each other, straddling the state line, and those counties were called Terekaka and Awerial counties. And sure enough that was a great starting point, because there was a lot of Guinea worm there. And then we fanned out from there over the course of 2006 and 2007, and then, you know, slowly but surely brought other areas under surveillance as they needed to be. And some areas were bad choices to put under surveillance, and some areas we took a risk and we were completely accurate. So, you go with the best information you have at the time, you know.


(50:31)
NH: But you, you brought together quite a large team did you not, the South Sudan-?

SB: We grew it; yeah, yeah, we had to grow it locally. I think there's over 150 field officers now. But that's something that we did immediately, we realized we have got to hire; we have to have some sort of structure of supervision to this program. This country is just too big. So, Makoy was able to advocate very successfully for state field coordinators, who have now been- and these are administrative health employees- they've now been absorbed, their pay is fully absorbed by the Ministry of Health. And so in that sense, I mean, there’s one small example of this program contributing to service delivery and establishing a permanent surveillance system in Southern Sudan.

(51:26)
NH: For other programs.

SB: For other programs, because people- these people are now going to be the IDSR- the Integrated Disease Surveillance and Response - focal points. And this system I would imagine will eventually get co-opted into that infrastructure for reporting communicable diseases, the notifiable diseases of interest in South Sudan. And already, I mean, we used the program since 2007 to support where necessary during outbreaks of infectious disease - measles, cholera, meningitis - as well as supporting delivery of interventions for malaria and trachoma. I'm trying to think what else, mostly malaria and trachoma.

(52:17)
NH: So, now, what is your family situation? Are you married at this point, have you gotten married?

SB: Yup, I'm married, and I got a boy who is nine months old.

NH: No, what I was thinking about, at this point, when you're in South Sudan.

SB: Yeah. Ann and I got married in 2005. We'd basically, I mean, we were going to get- we were engaged as it was, but things sped up a bit because of this assignment to Sudan.

(52:37)
NH: So you got married before you went to South Sudan?

SB: Yeah, yeah.

NH: Okay, and was in Ann in South Sudan at all; did she ever?

SB: On and off, at the beginning.

(52:47)
NH: Was she ever working in South Sudan with you?

SB: Yeah, after graduate school she worked in Nairobi to help us out with our procurement of supplies to come into Southern Sudan. For about eight months she did that; she set up the procurement system there. And then another person named Jamie Tallent came in and took over for her. Ann went to graduate school that fall of 2006, and then she came back to Southern Sudan.

(53:16)
NH: Back to Atlanta?

SB: No, to University of Michigan, in Ann Arbor. So we were apart for those two years, and you know she came in the summer in between and did her project in South Sudan looking at media habits among the Toposa tribe in Southeast Sudan. And then she came back in May and took a consultancy working on behavior change, communications in South Sudan from May 2008 through March 2009.

(53:46)
NH: And that's when you left?

SB: We left at the end of March 2009, yeah, had a baby on the way.

NH: Had a baby on the way, who's here now?

SB: Yeah.

(53:58)
NH: Okay, back to South Sudan for a minute. You worked with other NGOs, I'm assuming? In the various areas? With Lifeline Sudan, or no?

SB: Not so much. Interestingly, you know, you stumble across documents whenever you take over for someone. And, you know, one of the documents is a letter instructing the previous RTA to sever all ties with the NGOs that we were working with in Operation Lifeline Sudan. And this was at the request of Dr. Bellario, who is the, he was the, I don't know, the director, whatever you would call it, the, not the Minister of Health, but sort of the director, the Secretariat of Health, before the Ministry of Health was formed during the war. This was back in, I believe, 2004. So this directive came in 2004 I believe to Glenna. And then that relationship was severed. But with that came any ability to implement a program. And you can't set up a program and do it all alone with no Ministry of Health, and no NGOs, and no presence on the ground in South Sudan. So a lot of the data from 2005 is pretty much garbage. There were some accuracies in terms of trends, because there were some technical assistants on the ground. But, I mean, they'll even tell you all we could do is just count cases. We didn't have any type of support. And this is not to criticize anyone. I think it's just a function of timing, you know, you can’t cut your umbilical cord too early. It's about the same time while there's no capability to implement in Southern Sudan, also they closed the office in Nairobi, which was youronly way of supplying the program in Southern Sudan. So Ann and I had to go through the process of establishing sort of a one-person procurement function in Nairobi because we had no logistic support for even moving the program into Southern Sudan. So we're trying to buy trucks and fuel and food and just basic commodities so that people can live and survive in Southern Sudan. Because there were no markets at that time; you could not get goods anywhere but in Kenya or Uganda and truck them in. So we had to go through that pretty sharp learning curve. And I really do think that the lack of logistics capability and the lack of implementing partners made 2006 a really tough year.

(56:16)
NH: So they, The Carter Center had closed their office in Nairobi at that point?

SB: Yeah, yeah.

NH: That's when Kelly Callahan left, and no one followed her?

SB: No, Kelly was before Glenna. This is during Glenna's time, that the office closed.

NH: Okay, Glenna- it was closed after Glenna left, okay. Well, that did leave you out there in the field, didn't it?

(56:39)
SB: Oh, all we had was Lokichokio, and there's nothing you- yeah, it was.

NH: And if you're not supposed to be working with the NGOs coming out of Lokichokio-

SB: Well, and a bunch of those NGOs were angry cause the US - not the US, I work for the US now- The Carter Center used to be giving them grants. So this was a source of income for them. And the grant- I'm fully in support of the decision to have the relationship with the Ministry of Health, support the Ministry of Health infrastructure, and move in full into Southern Sudan. Because that's what will break transmission, make this a vertical program. But I think it's a question of timing, because we didn't have the capability ourselves actually to implement a program. So then you gotta go with, well, what's the next best option? You go with implementing partners. So these folks were getting money from The Carter Center and I'm sure they were upset about that loss of income.

(57:32)
NH: Interesting.

SB: And some of them were not using it properly, by all rights, and we were getting garbage from them. And some of them were doing really good. I mean, The Carter Center supported, through Operation Lifeline Sudan, some of these NGOs to break transmission in some of these states during the war. Western Equatoria state is an example of that; there used to be active transmission there. So together with technical support and funding, you had during the war The Carter Center was able to demonstrate that you can stop this disease. So, you know, that was a challenge. That was probably the greatest challenge we faced in Southern Sudan actually, was just coming in to nothing, and yet having all of this sense of urgency. At the time we were kinda getting pushed by Atlanta to develop this tripartite MOU and all this stuff with the North. And as I said before, the Southerners didn't want any part in that.

(58:27)
NH: Tripar- tripartite? What are you saying, tripartite?

SB: Like three parties, between-

NH: What three?

SB: Between the North, the South, and The Carter Center.

NH: Oh, OK.

SB:Yeah, and that was just really, really not the way to go down. And it took months to convince folks here that-

(58:45)
NH: You had to work with the people there.

SB: Well-

NH: had to work with South Sudan, with the Ministry there.

SB: Yeah, exactly yeah. They don't really want to get into it. We're not going to use health as a bridge to peace through a tripartite MOU. It's just not possible. They're not- there's just too much bad blood at that point in time. And I think there is, and there's going to be, a vote on a referendum. And you know, they'll decide one way or another how things are going to fall. And a tripartite MOU for Guinea worm disease ain't gonna help that.

(59:17)
NH: Okay, what were your areas in South Sudan? What were your states or regions, what do you-?

SB: Ten states.

NH: You had ten states.

SB: Yeah, in all of Southern Sudan, it's composed of ten states.

(59:27)
NH: No, which of those did you work in?

SB: Well, I was the Resident Technical Advisor for The Carter Center, so we worked, I worked, everywhere that The Carter Center worked. And we worked everywhere where the disease was active.

(59:40)
NH: I thought you had four- you had four major areas, I thought.

SB: Those are four starting points, and those are starting points within states. You know, you basically lined up- we even lined up those starting points based on where there were air strips, because we knew we were going to come into transmission season pretty quickly. We had to identify places with year-round access for the safety and security of the staff as well as for re-supply and for doing supervision. So, those four were the starting points. But we found that there was active transmission in seven states.

NH: Seven out of ten.

SB: And we poked around in the other states to see, you know, to backstop and make sure, okay, are these states really free of transmission. We just did some assessment visits in those states and didn't find evidence of transmission. And those were Upper Nile, Unity, and Western Equatoria state. Now, since then Western Equatoria state has had a small pocket of cases in an area bordering Terekaka county, so I think there was like one or two villages, but you know for the most part we could focus on those seven.

(1:00:47)
NH: What was- what do you feel like you accomplished, in that piece of time? I guess you don't have a sense of Guinea worm numbers when you came and when you left necessarily.

SB: Yeah, we do.

NH: Do you?

(1:01:00)
SB: Yeah, I mean, I think pretty good. I mean, there were 5,600 something cases in 2005. I arrived in November 2005. In 2006 the Ministry of Health was formed. Makoy became director of the program. We set up the system. Surveillance was activated, starting from those four focal areas and then branching out into other areas of those states and then to a total of seven states over the course of that year, and we detected over 15,000 cases. Now, did we miss some areas? Yes. Did we over-report in some of these areas or were reports falsified? Yes, I do think so. So what the clear picture is, I mean, I don't even really want to speculate- we originally reported over 20,000 cases, but we realized that there had been some double reporting, and so we cleaned up the database the best that we could retrospectively. And then we ended up with, I think, 15,585. The following year in 2007, we dropped down to over 5,000 cases, and then 2008 was 3,000 something. And then in 2009, 2,000 something, and I think the latest word I heard from Makoy was that they're on track in 2010 for about a 50% reduction so far- they're in the middle of transmission season.

(1:02:31)
NH: But it looks, it looks so promising.

SB: It's dropping, yeah. And when you see all the indicators were moving in the right direction. I guess this is why I'm so encouraged by South Sudan is that, you have cases dropping, reporting rate is at 100% now for endemic villages; whereas it was 63% in 2006. You have areas- we really have the country better sorted out and mapped now. The indicators for vector control are very, very high now, I mean, like, you know, ten times higher than they were in 2006. Indicators for all the other interventions are much higher. And then the one thing that's really lagging in South Sudan, and this is just sort of a travesty I think for the international community, is safe water coverage.

(1:03:16)
NH: It's such an enormous-

SB: Sector can't get it together.

NH: It's such an enormous area, such enormous area to cover.

(1:03:22)
SB: Well, such enormous need, yeah. Well, there's not, you know, South Sudan is sparsely populated. It's an area the size of Texas, but, you know, there's only like, I mean, it depends on your source, but generously you could say ten million, but more likely somewhere between five and ten million people. There's just not many people living there. So, and I think one of the challenges for water development though is the settlement pattern, because people are- this is a challenge for surveillance too, and the delivery of any interventions and mobilizing communities, is you're dealing with a clan structure. People settle very- in isolated circumstances in that you'll have one homestead, and then you might move another 400 meters and then another homestead. So it makes even doing surveillance like walking through a village very, very difficult. And figuring out where one village ends and another one begins, that's also very difficult too. In fact, many of the Southern Sudanese say that we don't have villages.

(1:04:28)
NH: Oh really?

SB: Yeah.

NH: They have-

SB: They refer to other distinctions.

NH: They have tribes, but they don't cluster together, like some do.

(1:04:36)
SB: They have tribes. No, no, everyone lives within their tribe. I didn't come across many, except for large towns where tribes would mix up. But within tribes there's clans, and within clans there's sub-clans, and within sub-clans there's families. So it's a very complex system that's very, how would you say it, amorphous in a way in terms of the leadership structure as well. There's a lot of leaders. Decision is made typically by consensus, as opposed to say, having more of a strict hierarchy that you might find in Ghana and some of the groups there where there's a king; there's, you know, paramount chiefs; there's, you know, a real strict hierarchy whereby you know who the chief is in the community; you go visit the chief; you ask for his permission to work there; and you get your permission; you can work through the chief. There's no one to work through very easily at least in a lot of these communities in Southern Sudan, because there's so many stakeholders. It's more like you have to assemble twenty people, and then you work through those twenty.

(1:05:43)
NH: And you have a lot of languages, you're dealing with also, are you?

SB: Yeah, a lot of different languages. But, you know, the field workers they spoke English in addition to their tribal languages, and Arabic as well.

(1:05:56)
NH: Now, while you were there, you're in a peaceful situation, but you do have, you do have some dissonance within Sudan. Even though they're at peace with the government of Sudan, you're having some struggle going on politically. Did that affect you in terms of your risk? Did you feel at risk at all in Southern Sudan the years you were there, because of political struggle?

SB: No, not because of political struggle. I mean, there were some skirmishes between the North- the troops from the government of Sudan - and the government of Southern Sudan, but only in border areas where we were not operating. Just, there didn't happen to be Guinea worm transmission there, so we didn't have operations there.

NH: OK.

SB: I think more the security threat for the people - and this is on an ongoing basis and has taken a lot of lives in Southern Sudan, including lives of some of the staff there and volunteers - is just the ongoing inter-clan conflict within tribes primarily - over cattle, grazing land, old blood feuds. And there's just a lot of weapons out there, too many unemployed young men. And I think whenever you have that combination, you can see it here in the United States, it's a dangerous mixture.

(1:07:25)
NH: Your major accomplishment in Sudan, what do you see as your major accomplishment?

SB: I think the major accomplishment was probably just working with Makoy to get the program set up, you know.

NH: The whole management of the program.

SB: Yeah, yeah, every dimension of it, from logistics to the intervention delivery to surveillance, advocacy. It's a pretty- for Southern Sudan standards - it's pretty amazing how much effort went into it, and then now how well it works. And I'm really proud of the staff there, they did a great job.

(1:08:11)
NH: Did you bring any of that staff together? Were they there when you got there?

SB: Oh no, I hired-

NH: Oh you're talking about growing the big staff.

SB: Yeah, yeah, yeah.

NH: You're talking about the big staff

SB: No we hired all of them, and had to fire some too.

NH: Sorry.

SB: Yeah, there's always some of that. And those are probably the most challenging things, is dealing with people who don't do the right thing.

(1:08:32)
NH: And the most beneficial, they keep going after you leave. It's on track.

SB: Yeah, I feel really good about that, about the handover with Alex Jones, who's the current RA. And he's doing an excellent job there. I mean, we spent about eight months doing the handover. Is that right? Between October.. about six months.

NH: That's a nice piece of time, isn’t it? A nice piece of time to have that-

SB: Yeah, we had about a six month handover, and for the last three I worked in the field.

NH: Oh, did you?

(1:08:59)
SB: So we sort of switched roles actually at that point in time. So I just worked in the field. And, you know, I'd come back to headquarters and help him out with a few things. But for the most part I was just in the field, which was a very nice way to leave the program there, to have the ability to go back into the field full-time and be able to contribute in that capacity, and take those memories back.

(1:09:18)
NH: But you're there for him, with any answers to any questions, for those six months though.

SB: Yeah, yeah, I mean, now we just correspond briefly just how are you doing, that sort of thing. He really has a good working relationship with Makoy and with the staff there. And I have all the confidence those guys are gonna finish the job.

NH: Great, what is his name then?

SB: Alex Jones.

(1:09:42)
NH: Alex, Alex Jones. If he comes back into town, please remind him that I'd like to-

SB: He's gotta have an interview, right?

NH: Yeah, right, so remind him if I don’t hear from him.

SB: No he's a good person to interview.

(1:09:55)
NH: You and Ann are back in Atlanta now?

SB: Yeah.

NH: And you're with CDC?

SB: Yes.

NH: How has life changed for you? Have- how is life back in the United States after so many years in the field and in Africa?

(1:10:10)
SB: Well, I don't know. We have those days. And we had one maybe two days ago when we were like, well, we should really go back to Africa again. But, you know, I would go back to any of these countries again and work under the right circumstances; I really would. I think the Guinea worm eradication is a wonderful program. It's something I'm grateful to have been able to participate with. You know, life changes a lot. I don't know if it's so much life changing a lot coming back to the United States as it is life changes when you have a baby. And I think that happens to anyone who starts a family. So I don't know, we had a lot of changes in 2009. You know, we came back to the United States, had a baby, we had a home, got a dog, we changed jobs, so a lot of changes at once. I don't know; I guess I'm probably still processing it. But I think the biggest change is having a baby. I mean, moving back and forth between the United States, I mean, sure there are things that are annoying, but there's-

(1:11:08)
NH: You've been doing that for a long time, back and forth.

SB: Yeah, you kind of learn to appreciate the absurdity of it all.

NH: And to step in the different worlds pretty easily.

(1:11:20)
SB: Yeah, and the United States is an absurd place. And so is Sudan in some ways too, and you learn to, I think..

NH: But one is simpler than the other one perhaps.

SB: -appreciate it.

NH: -is that possible?

(1:11:32)
SB: I think all of them have complexity, yeah, sure. I mean, very complex traditional systems in Southern Sudan, but, you know, I feel like we were scratching the surface of, in terms of how to relate with the societies there, with behavior change for Guinea worm eradication. It was a tremendous amount of complexity.

(1:11:58)
NH: Do you anticipate going back to the field? You and Ann and Sammy?

SB: Well, I mean it depends what we call the field. You know it's funny like I do international work for CDC, and you know their vision of the field is a little bit different than Carter Center's vision. And I hope that I always keep that perspective even in my work with CDC. I've made the offer with Ernesto, I'd be happy to do some work for him. You know, I've got comp time. My boss has said, yeah, go for it. There's a lot of respect at CDC for the work that The Carter Center does and that I did with them. And I'm happy to have that support. I think with this type program, would I want to do something like this again, I think so, yeah, of course. What would it look like? I don't know, I mean Guinea worm is so unique, it's so special. I don't think that any other experience will compare in a lot of ways. And, you know, maybe it shouldn't. So I think that, yeah, I'd like to go to the field again and do something community-level again. Will that be with CDC, or some other group? I don't really know; we'll see what happens. It's hard to get into the field when you're with CDC though; there is a lot of restrictions on your movement.

(1:13:19)
NH: Well, when you get to certain levels too, it's hard to get a field position.

SB: Yeah, I mean, for them you can get field, you know field positions, but you can't get grassroots.

NH: I'm talking about field positions. I'm not talking about the field in Paris; that's not what I'm talking about.

SB: Yeah, you can't go out; it's harder to get muddy. But you can go into some of the capitals, some of the positions in capitals in these countries, yeah. That's more of what the field is for CDC. But even then, you know, and there's some wonderful field workers in CDC too, they do, they are able to get engaged in some field work; but it's not as solely focused on that as The Carter Center's efforts are. Which I think is something that is a comparative advantage for The Carter Center as an organization. And I hope that they are able to build upon the experience of the eradication campaign to strengthen some of these fledgling systems in primarily sub-Saharan Africa. But to me the greatest benefit to Southern Sudan beyond Guinea worm eradication with this program is giving people the confidence and the trust with the communities and the skill sets to actually have field extension services, and start vaccinating those babies, and getting children de-wormed, and bed nets into the hands of people. And I hope that there is a vision of converting what exists to that kind of capability, cause there is a real opportunity there. It has to be timed properly so as to not compromise the eradication objectives, but there is an opportunity there. With the right partners and commitments, it can be done.

(1:15:11)
NH: Steve, are there any questions you wish I had asked?

SB: No.

NH: That I didn't?

SB: It was a very good interview.

NH: Is there anything else you'd like to add for the public record?

SB: Nope.

NH: No?

SB: That's it.
(1:15:22)

NH: Thank you, Steve, for taking this time and sharing with us today, and leaving a record for future generations.

SB: No problem.