Global Health Experience
“Reculer pour mieux sauter”
Over lunch last month in a restaurant in Lahore, a colleague from the Punjab Ministry of Health told a story she’d heard on a recent work trip to Turkey. The fable, as I’ve since researched, is well-known in Turkish folklore and will be familiar to those who have visited the Maiden’s Tower in Istanbul. According to legend, on a tiny islet off the city’s coast an emperor had a tower built after an oracle prophesied that his beloved daughter would be killed by a venomous snake by her eighteenth birthday. To thwart the prediction, the emperor imprisoned his daughter in the erected tower, fortified by a surrounding wall and separated by the sea from the land-dwelling reptiles. On celebration of reaching her eighteenth birthday, the maiden was sent a basket filled with fruit and — as per the lunch version we were told — out of a pomegranate a poisonous asp emerged which bit the princess. Variations of the story are litany — the basket can be of fruit or flowers, the sender can be the father or a prince in love — but the fatal outcome for the daughter is always the same.
The parable of the Maiden’s Tower has multiple meanings, but one interpretation was particularly poignant during the trip to Lahore. Home to around one hundred million people, the Punjab is the most populous province in Pakistan and is currently undergoing a period of transformation of its public health system. As part of a programme of support to the government of the Punjab, the purpose of our four-day visit to the capital city was to review the province’s Institute of Public Health (IPH) — an academic organisation primarily devoted to postgraduate teaching, training and research — and to make recommendations on the IPH’s place in the planned new public health landscape. Of the many evidence-gathering meetings we had — with officials, policy-makers, students past and present — one session stood out emotionally and psychologically: a period of almost three hours spent with a group of 25 mid- and senior-level staff members of IPH.
Through the first third of this session, the level of dissatisfaction was palpable. Staff openly expressed unhappiness about a range of important issues: consistent under-funding; year-after-year of the institute being run down; lack of operational autonomy from government; inability to make necessary senior appointments; and of being blamed for outcomes for which they felt they were not responsible, such as high Masters student drop-out rates and poor exam results. The atmosphere was negative, feelings were of passivity and powerlessness, and the outlook was perceived as bleak. Out of such space it is hard to move forwards.
So, to try and break the deadlock, I challenged staff to name the ten best things about the institute. Initially this proved hard, as if staff had almost lost sight of, or forgotten, the significant qualities of their place of work. But slowly they came around, then seemed to relish the opportunity to share the institute’s strengths: the IPH contains the only library in the whole country dedicated to public health; the IPH is unique as an academic institute in also providing high quality community health services to those living locally; links with district health services across the province are unrivalled; the dedication and heart of the teaching fraternity; the tremendously high regard in which students hold the IPH and its staff; and the extraordinary contributions to public health that graduates have subsequently achieved, and have attributed to their education at IPH. Plus more.
On a roll, we then did the same exercise about aspects that staff could hold their hands up to, and admit that the institute could do better. Previously reticent, their suggestions now included: enhance the quality of assessment of their own teaching; quantify student experience and satisfaction through annual surveys; modernise the variety and length of courses; implement a research strategy; develop staff performance indicators; showcase their strengths better and make it clear to others that they are an institute willing to learn and grow.
The atmosphere had really changed. Passivity was replaced by a sense of the importance of being pro-active and engaged in the change process. Pride was overcoming deflation. Creative solutions were suggested, and the positive prospects offered by the new public health system were tangible. The future perhaps even appeared less bleak.
So, we return to the princess in the tower. Or, rather, to the father who put her there. Whether you believe in prophecies or not, he was trying to achieve the impossible, to control our external circumstances. Ironically, therein lies the true myth, that we can somehow master the world to bend to our will, a fabrication designed to make ourselves feel more secure, when a better understanding of the true insecurity of the human condition would be more helpful.
And in trying to control our external circumstances we tend to hold on to the past, rather than living in the present and looking to the future. The vitality of engagement is replaced with fixation on a certain outcome, a thankless endeavour to either keep things as they are or make them as (we think) we want. All of which leads to a spiral of tunnel vision, negative thinking and anxiety, and a failure to see other possibilities that inevitably exist out there. The princess’s father failed to notice the risk posed on the actual eighteenth birthday; and an inability to let go of the past meant, initially at least, that IPH staff struggled to grasp the opportunities of the future.
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Over the past months, I have been embarking on my own ‘letting go’, which explains the delay since my last Global Health Experience posting. Before Christmas, I handed over the global health department that I had led for the past eight years: a parting from international projects I have set up and relished, and a drastic reduction in interaction with staff I have enjoyed working with over the years. It’s not been easy, but the shift has facilitated an exciting career transition towards global health possibilities in hitherto unexplored directions.
As part of the process I was steered towards an excellent book, Working Identity, by Herminia Ibarra of Harvard Business School. Towards the end, the author reflects on the French phrase at the start of this piece, reculer pour mieux sauter, which translates as “stepping back to better leap forwards”. Change isn’t always easy, but to engage positively requires stepping back, letting go, and leaping forwards. It also requires a degree of bravery and, perhaps more importantly, some faith that everything will be okay. To be rewarded with the bright future that the Punjab’s new public health system can provide, the vibrant, intelligent, committed and passionate staff of the IPH need to let go, be brave and find that faith. Faith that the maiden’s father failed to have.