Archive for the ‘Liberia’ Category

The Liberian Correctional Palace

April 22, 2010

Yesterday, I went with Dr. Kerry to the “Liberian Correctional Palace” just outside Zwedru – the Grand Gedeh County main prison. Not knowing what to expect in a Liberian prison, the road there gave a quick sense of its remoteness. A UN driver took Kerry, a nurse named Ernest, and me along the dirt mud road running through the bush outside town.

Kerry started doing a weekly clinic at the prison after she kept seeing a number of prisoners present at Martha Tubman Memorial Hospital in Zwedru where she predominantly works. Many had signs of malnourishment and with protracted courses of various health problems. She ended up writing a report that helped change feeding and other policies at the prisoner. The County Health Team should have been seeing the patients but they were not doing so with any regularity. Now, Kerry sees patients once a week at the “palace” (this is what the prison is called here) and refers those that need further care to the hospital within the next few days.

When we arrived, Kerry talked briefly with UN-POL and UN-MIL UN troops/officers who are helping teach how to run the prison. The India UN-MIL unit is now stationed here for that purpose. We checked in at the prison gate and signed the prison visitor book. Family members and pastors appeared to be the main visitors but not with much frequency. On a piece of paper sitting atop the desk, there were 4 crimes listed on the slip and nothing else: rape, murder, attempted kidnapping, and robbery. We headed into the prison, met some friendly guards, and stopped at the clinic, basically a set of 2 rooms with a desk in one and some benches in both. Outside the clinic window facing inside the prison, I saw the concrete compound where the prisoners could exercise all surrounded with the standard barbed wire rings.

The prison houses 115 persons, 111 of them being men. Of those 111, 35 presented to clinic yesterday with afflictions such as typhoid, dysentary, malaria, hernia, fungal skin infections (secondary to hygiene and the hot, humid weather here), constipation. Ernest employed top-notch efficiency in a crowded, hot room. Formerly from Sierra Leone, he worked with Doctors Without Borders there before coming to Liberia to work as a nurse. Kerry finds that he performs at a level higher than most physician assistants. With 35 patients in just under 2 hours, we all had to be efficient, though I was the weakest link. Ernest was both triage/intake staff and pharmacist. Kerry saw each patient in the interim. If she thought the patient had malaria, I did the Paracheck malaria test. A simple test, I used a lancet to prick the inmates’ fingers and then used a rapid diagnostic tool using some reagent drops to look for a certain strain of malaria endemic here. None of patients tested positive, but Kerry was concerned about the integrity of the particular kit box we had for the day. So she’ll keep tabs on their symptoms for next time.

The guys were pretty jovial the whole time. I didn’t know their crimes, but many were those listed on that little white slip of paper at the entrance I suspect. Some probably ask to come to clinic weekly just to see Kerry, and it was clear that they like what she is doing and the care she provides them. A 78-year old frail man was particularly memorable. As a term of respect Kerry and the other inmate who helped him called him “papa.” He had what appeared to be a Tinea fungal infection on the back of his neck. I couldn’t help but think what this man has seen in terms of Liberia’s history. The younger inmate’s affection towards him was endearing.

He wasn’t the oldest inmate. Of the 4 women here, 2 are 89 and 98 years old (the oldest people by far that I have heard of here). Why are they in? Up to 3 of the 4 were accused of witchcraft. Kerry didn’t have time to tell me the full story, but for all the anti-witchcraft accusation signs in the country, it seems some women are still getting jailed for it. Fighting on behalf of those women’s rights might be a good project for the nascent group Zwedru Women United for Change being run by Agatha Toure in TH, and we intend to pass that message on. Just the first day I was in Zwedru, Agatha said a few women had been jailed for witchcraft accusations.

Just after we packed up the remaining drugs, kits, and forms (let’s just say the lab work wasn’t the most hygienic of situations given the rapidity and lack of safe disposal equipment), I stood by the interior bars facing the exercise compound surrounded by cells. I had my camera, but I didn’t take what I thought was a powerful picture: a young man, Nubian in skin tone, hands clasped as in prayer intertwined with the fence, and alone, kneeling on the concrete. Bright sun in his face, barbed wire above and below him with the fading yellow-painted, decrepit walls around me. There wasn’t any particular “message” I saw in this image, but it captured some facet of prison life that only a photo might do.

As we left, Kerry showed me a set of gardens just outside the prison walls. Inmates now get some of their food from it. I didn’t know what to expect for the day, but the generally upbeat spirit of the prisoners was not something I would have expected. I tried to lighten up the finger jab by having them guess their malaria status first. Men are often the biggest babies when it comes to being a patient. I should know as one of them. So in a rural prison in Liberia or a hospital in Illinois, I know at least that transcends cultural boundaries and that honoring prisoner health rights is not only a professional ethical requirement but can be a meaningful one at that. Thanks to Kerry for taking me along and for standing up for her patients. I look forward to hearing if TH health accompanier supervisor Alphonso Mouwon’s idea to start TH health talks for the prisoners takes shape soon.

Advertisements

Traveling around Ohio is slightly different

April 16, 2010

Liberia is about the size of Ohio. Let me assure the reader that it takes much longer to travel around Liberia than Ohio. I’ll take a small tangent at this point. The infrastructure here relates to the country’s post-conflict environment, evidenced by the deficiencies in infrastructure. Take roads. Many African nations have poor roads – this is true in Uganda and Liberia, less so in Rwanda. Whereas Uganda has a well-developed road network – albeit with many roads in dire need of update – Liberia has neither adequate roads to get around the country nor well-paved roads. Most African nations have taxi/motorbus/bus services to get around the country at locally affordable rates. Liberia has none – that really made an impression upon me. Not only is private transport expensive, it is often difficult to arrange timely. In order to get to the southeastern towns and villages in Liberia, one has to go on the road to Zwedru from Monrovia. This is completely out of the way, but no roads exist connecting Monrovia to other coastal towns of the southeast.

The drive was often beautiful. Amos, a TH driver, provided much entertainment. He is affectionately known as “the director of smiles.” Occasionally we’d see what I thought might be primary rainforest but mostly we saw secondary rainforest growth. Rubber trees are an important crop here, and we could easily see where they had been harvested and replanted from the road side. Less village/town activity appeared the closer we came to Zwedru. In one town, an impaled monkey sat atop a stick at the road check. At another road check, a live monkey attached to a rope hung out with market vendors. No other animals crossed our path. The bumps, the dust, the unpredictable events of the day kept my excitement up, but the womb-like lull of the bumps put me to sleep for a bit of the 10 hours. That is, of course, until a big bump threw me off the bench into the aisle of the back of the vehicle!

We passed a number of UN bases along the way organized by country. Bangladesh, India, others. Of the many sights and smells we came across two struck me: the river separating Nimba and Grand Gedeh counties and a gleaming, large Chinese-funded hospital under construction. I plan to take a picture of the river on the way back. To make a simplistic generalization, when China wants to exploit another country’s resources, it usually pays in part with road development and infrastructure improvements. China won’t staff the hospital, and most likely won’t supply it, but the building itself definitely contains potential for area people. Given the health worker shortage in Liberia, the hospital has a lot of work ahead of it once it is completed. I noticed one more thing of note: a church named the “Lovable Lutheran Church.” Those Liberian Lutherans – they’re so lovable.

Chinese hospital in Nimba county

We arrived late afternoon to Zwedru with a number of TH people awaiting our arrival. We met some of the security guards, some of whom I’ll write about in more details later. We settled and went into “town” with Ana and Kerry.

Zwedru has an interesting history. The home town of former president Samuel Doe, he paved some of the main roads in the town when running for president back in the 1980s. His abandoned palace, now inhabited by squatters, sits near the entrance of the town. Road lights dot the roadside, and there is even a water tower. A city of 20,000 some plus people, it has a small town feel. But only this town which appears as a town may be more similar to a village. There is no grid electricity in the town – only generators for those who have the luxury of having one. There is no running water in the entire town. Not only no running water, one cannot buy bottled water here either. Well water or bust. But let me tell you what we can – and did – get: pizza.

One of the only 3 bar/restaurants in town – Florida – recently started serving pizza recently. And it is decent. So Ana, Kerry, Roona, and I headed there for informal orientation over pizza and drinks. Ana ran into a woman, who I will call “Dee” for the sake of privacy, that she met when she was here in January. Dee offered hilarious company for a little bit during dinner. Her story is interesting. She came to the US with her family during Liberia’s civil war. She’s hopped around a number of US cities. And hopped into a bit of trouble as well. She ended up in jail a number of times for crimes related to sex work, drug use/dealing, and other things. She stood out among local Liberians, mainly for her American English (versus Liberian English), her level of gregariousness, and because she was well-nourished (not overweight, but not as skinny as most Liberian women are). Dee didn’t really meet any stereotypes I could have thought up about a deported Liberian national from the U.S. She told us how she’s moved on, about her boyfriend on the flight of deported people, her business aspirations, and a little bit about her religious beliefs. I found out that she lived in Chicago in a pretty rough Westside neighborhood. Her father is ill and in Evanston, IL so I intend to bring back a letter from her to him. She also gave Ana a phone to give me since my mobile phone wasn’t working. Not something I was expecting, a mobile phone to borrow from a deported Liberian woman from Chicago who is now in rural Liberia. (The phone ended up not working either, but the gesture was very gracious.)

Roona and I went back to the guesthouse and got ready to call it a night. Until las cucarachas. The cockroaches. Yes, they are big and plentiful. In terms of yuck factor, mine was the lowest among Raj and Roona. It is not because I’m tough – it is just that they were in my otherwise very clean Ugandan apartment, and I just had to get used to them. Even the occasion when a large one crawled on my neck while I was on the phone, I was surprisingly calm. (Subsequently I ended its life and it was my Facebook profile picture for a while back in 2008.) All this brings me to the TH guesthouse…

(More pictures to be posted when I come across better bandwidth.)

Did you contact the OIC and CHO after reading the MOU with the MOH but before checking with CHT for input from the TTMs? OK. TTYL. LOL.

April 15, 2010

And so the non-governmental language of Liberia quickly needed to be added our vocabulary as we sat in on meetings with the following NGOs on Monday, April 5: Merlin, Action Aid, Clinton Foundation Health Access Initiative, and the External Aid Coordinator’s Unit. (Don’t worry, they all have acronyms, too.) Each partner listed has some exciting partnership with TH which we discussed during each meeting. Action Aid will be working with TH’s women’s group as mentioned a few posts back with PhotoVoice. Clinton Foundation’s work particularly interested me – they provide technical and consulting assistance to the Ministry of Health in a capacity-building manner. I’m sure that entails its own frustrations, but also provides interesting opportunities to strengthen the ministry’s capability to improve on its health commitments to Liberians. They have an office right in the corridors of the Ministry of Health.

Lunch entailed some fufu, a West African cassava-based product that looks like the blob (I can’t think of a better reference for comparison.) I had it in Ghana many years ago, but I don’t think my body remembered. I’ll leave it at that – gastrointestinal stories become less entertaining over time. What was entertaining, however, was the construction worker who was being teased by a fellow construction worker moments after I started feeling impacted by fufu. In with fitful anger, he said “I’m going to go pee-pee on you.” I think the threat was real. After some rest mid-afternoon, I reconnected with Roona and Raj when they returned from their last meeting. We did some grocery shopping for our wonderful processed dinner, last in Monrovia for a while – Laughing Cow cheese (it doesn’t need to be refrigerated), canned pears, canned chicken spread product, canned baba ghanoush, canned soda, and some bread. Essentials in a country that imports so much of its food, be it in the market or Western-style grocery store. Well-satiated, we packed it up and prepared to get up for our 6:30AM departure for Zwedru.

For Liberian recipes see: http://www.foodbycountry.com/Kazakhstan-to-South-Africa/Liberia.html

Easter in Monrovia

April 14, 2010

A year ago I spent Easter Sunday in Bujumbura, Burundi as detailed elsewhere on this blog. My friends and I went to a mass in the main cathedral led in French. The children’s choir truly had angelic voices. Although I don’t speak French, there was an unmistakable, familiar rhythm to the service. A memorable day during a memorable trip. That was a year ago.

This year I fought jet lag and slept the latest I think I have ever slept – just before before 1PM – in Monrovia, Liberia. Not so memorable. We had intentions to attend an African service at a Lutheran church somewhere in town; however, our contact we met on the plane didn’t get back to us. Needless to say, the added rest expedited the jet lag recovery.

I’m writing this short post days after Easter. Since then I have begun to hear stories of the trials, tribulations, and hopes of the Liberians with whom I have met through TH. Each time I find myself on the African continent, I find myself struggling with how I talk about my experiences, but more importantly, conveying their experiences. I want to capture the oppression but not at the expense of the strength of the human spirit in a world with far less material comforts, essentials, and social recognitions of human dignity than in high-income countries, where there it is not perfect either. It’s an ongoing discussion for me, one that continues to be shaped by experience, discussion, and reflection.

I brought a number of books with me: The Roads of Man by Ted Conover, Checklist Manifesto by Atul Gawande, This Child Will Be Great by Ellen Sirleaf-Johnson, The Birth of the Clinic by Michel Foucault, and A Hidden Wholeness by Parker Palmer. I also brought a stack of magazines, among them The Christian Century, a mainline theological magazine, which I have enjoyed for years. An article I read the night before Easter speaks to some of my thoughts on human expression in many of my African continent experiences. I’m excerpted a little bit below. Although it comes from the perspective of the Christian tradition, I think the theological dimensions apply widely for all readers regardless of any/no religious tradition.

“…On two mission trips to Haiti with undergrads, there was widespread agreement that the most disarming thing about the country was the laughter of the children, along with their raucous singing. How dare they sing when their life expectancy is so horribly short? Was their laughter an escapist respite from the tragedy of their lives, or a smart rebuke to our assumption that their lives were trapped in tragedy?…The insufferably earnest releases from our church agency presume that the morally attuned among us, the truly courageous, are the ones with the guts to admit how bad things are in this terribly flawed, fallen world… But those singing-through-their-tears Haitians make me wonder: a truly theological analysis suggests that we may be meant by God for music, destined for joy. Maybe our fitful good deeds are not the end of story. The church’s relief bulletins rarely include that theology along with its lists of sins and disasters. This is what you get when anthropology over takes Christology – it’s always Good Friday. What’s dead stays that way…” From “Now can we sing?” by William H. Willimon

There is singing. There is joy. Everyone should know. I’m not here to report on that solely, to downplay or overinflate it. Everyone deserves a lifetime to spend with their friends and families, to pursue their interests, to be treated with dignity. And by all indicators some societies are doing markedly better jobs healing and promoting health than others for a number of complicated reasons, including access to health care, health services, medical supplies, etc. That’s a reality, front and center with joy. But for this Easter in a country with dismal (but improving) health indicators, a country where in a report I read today that an infant mortality rate of 110 per 1000 births is “showing significant improvements,” if I’m honest to myself, I have to say “amen” to character and spirit of Willimon’s reflection after 6 years of experiences on the African continent. The needs don’t dissipate because of joy, but song in part reminds us of who we are and what we are to do.

Monrovia April 2-3, 2010

April 5, 2010

When I step back for a moment to contemplate it, I find the stark infrastructure and economic contrasts between capital cities truly remarkable. On my way home from Uganda last year, the acute contrast I saw within 24 hours was between Kampala and Reykjavik. On Friday, April 2 I spent 2 hours in downtown Brussels during a layover in the morning and then the evening in Monrovia, Liberia. One city with guilded exteriors, prolific chocolate shops (stereotypically true), and immaculately clean compared to another city with bombed out buildings from its country’s civil war, a few very well paved roads (a positive sign of improvement), and one not to be walked around at night. The rhetorical, perennial question lingering (when one brackets national sovereignty and history, of course): why do these stark contrasts persist?

In Brussels shortly before departure, we talked with Kimmie Weeks, a Liberian guy who has repatriated to Liberia after being in the US during Liberia’s civil war. He has been a significant child rights activist (http://www.youthactioninternational.org/yai/), and people at the airport from different countries came up to him given his past media presence and work. We all boarded, and Roona, Raj, and I landed in Monrovia later on April 2. As we descended in the air, I viewed the dense, verdant foliage meet up with the ocean with eagerness. The air appeared steamy – I knew what to anticipate weather-wise. We disembarked from the plane into 95F air with near 100% humidity. The familiar exhaust smelling air I’ve experienced on the airport tarmac in African and Latin American countries brought a flood of memories, reinforcing the power of the olfactory system in memory recollection. We waited in a chaotic line to have our visas stamped. Thankfully, my luggage arrived though Raj’s did not. We met a very kind Tiyatien Health staff member, Ben, after leaving the airport. We bought some delectable, simple bread at the roadside and started the 45 mile journey to Monrovia.

The Monrovia airport was built by the US military during WWII to facilitate exportation of rubber tires for the Allied forces in Europe. The location so far outside the city was chosen because Firestone has a nearby rubber plant. (Firestone has been in the country since around 1920). We passed many families on a very paved road as we left the airport. Rudimentary mud dwellings dotted the roadside, dense jungle-like foliage ended behind the homes, and a beautiful steamy sunset welcomed us as we drew closer to Monrovia.

The most memorable part of this road trip was Ben’s story during Liberia’s civil war. Trained as a physician’s assistant, he ended up provided care to the warring factions at different points in the war. One particular day, rebels had come near the school where his 2 children were attended. He found out that his kids were bused away safely, but rumors abounded that children were being abducted, adopted, and killed. He described the environment at the time, the fear, and the hopes for the future. As I felt in Rwanda and Burundi last year, the ramifications of such stories on a society and its individuals were rather unfathomable to me in the context of stable upbringing. We capped off a great conversation with a discussion about President Ellen Johnson-Sirleaf, the current president and the African continent’s first woman president. There’s an upcoming election, next year I believe, and we spoke about her and her competition.

We met up with Kerry Dierberg and Ana Weil, the former a Massachusetts General Hospital (Harvard) Durant fellow who agreed to work for Tiyatien Health in Zwedru during the fellowship. They were eating dinner at Golden Beach, a restaurant on the beach in Monrovia. Monrovia’s beaches are dangerous for expats in terms of security and undertow, and so being able to enjoy it at this restaurant was a great venue for us. We listened to Kerry and had some good introductory conversations about health in Liberia and TH operations in Zwedru. The connections among Raj, Ana, Kerry, and Roona are fun to trace. All of them except me have affiliations with Harvard and/or Johns Hopkins and had other contacts related to those institutions in Monrovia that they were not expecting. I enjoyed watching the energy of rekindled relationships.

Saturday April 3, we started the meetings en masse, which as I write this are ongoing through April 5 evening. We started on Saturday meeting with a senior leader in the National AIDS Control Program about an upcoming shared grant roll-out in Zwedru where we will be heading in a few days. (Zwedru, a southeastern Liberian town 20 miles from the border with Côte d’Ivoire, is TH’s main headquarters in Liberia.) We grabbed some street food and then headed to downtown Monrovia.

We bought some odds and ends on the main drag, Randall Rd. Events included a good falalel sandwich at a Lebanese eatery, stocking up on groceries and supplies before heading to Zwedru (all expensive because almost everything in this country is imported), and I thwarted an attempt of someone opening my backpack (I guess I learned some street smarts in Uganda). I should emphasize how friendly I find Monrovia overall right now! We then headed back to our air-conditioned guest house, a seductive luxury that we will quickly need to be accustomed to being without in Zwedru. As we were about to nap, we received a call from a programs officer at UNHCR-Liberia (United Nations High Commissioner for Refugees). A gracious man, we met with him and another UNHCR staff woman to talk about further building UNHCR’s relationship with TH. We also showed him a PhotoVoice project that took place in Zwedru with some former US TH volunteers. PhotoVoice (http://www.photovoice.org/) is an educational modality with a mission statement “to bring positive social change for marginalised communities through providing them with photographic training with which they can advocate, express themselves and generate income.” When that TH video gets posted on the internet, I will definitely post the link and provide more explanation.

We spent the rest of the day at the cafe of a nice hotel overlooking the ocean in order to discuss some issues in development work, goals for the upcoming weeks, and to enjoy the internet. All sorts of expat personalities shared the tables around us. Some military, some business, and most doing activities I can only imagine at this point. The stories here are undoubtedly plentiful and outside the type of my daily conversations in Chicagoland. The acronyms and vocab remind me again of my year in Uganda and some its excitement, success, frustrations, and failures. The evening finished with the appearance of one of Raj and Roona’s friends – Ranu – who is a medical resident in the Global Health Equity program at Harvard’s Brigham hospital and who is here independently consulting the Liberian Ministry of Health. His story is an entirely different post…

For now, listening to the delightful dialect of Liberian English spoken, re-immersing in the energy of change and all the complexities it entails, and working with an organization committed to community-driven solutions to problems keeps me revved. I leave this post with one comment by Kerry that I found inspiring that I will summarize and not do justice to in its eloquence: “some level of despair is what helps keep me motivated in advocating for my patients.”

Tiyatien Health/Liberia: A pre-departure introduction

April 2, 2010

A longer introduction to come, but today, April 1, I leave for Liberia to work with the organization “Tiyatien Health.” (http://www.tiyatienhealth.com) “Tiyatien” means “justice in health” in the Kwa-dialect spoken among some people in Liberia. Liberia has a rich, complex, and often turbulent history. Many simply associate Charles Taylor and child soldiers with Liberia when they hear its name. I will write more about those events along the way and hope to relay a fuller picture of daily life, the problems of the past, and Liberians’ hopes for the future.

Briefly, I will be working on a few projects for the organizations including using a tool to evaluate community health worker attitudes and ideas to improve patient care and the organization, surveying patients who are loss-to-follow-up and assessing side effects of medications they may be taking for depression, and working on issues related to distinguishing between demoralization and depression as well as clarifying some wording and data issues with a tool already in use for depression screening. I am very excited to be part of the TH team on this trip, and I am traveling with the organization’s co-founder – Raj Panjabi and 2 other medical students, Ana Weil and Roona Ray.

A few statistics until I have time to write more:

-There are estimated to be 122 doctors for 3.5 million people (http://www.mg.co.za/article/2009-01-14-liberia-battles-crippling-shortage-in-health-workers) in Liberia.

-In a multi-stage random cluster survey around Liberia (http://jama.ama-assn.org/cgi/content/full/300/6/676), researchers found 40% of Liberians surveyed met the criteria for major depressive disorder and 44% met the criteria for post-traumatic stress disorder (PTSD).

Stay tuned for more stories and statistics, history, and a travel adventure or ten.