Perilous journeys and additions to the family

For the few of you reading my blog, you know that I travel a lot in to the interior. Some of you also know that Liberia receives one of the highest rainfalls in the world. Traveling during rainy season is quite painful. The tracks are rough, the small portion of paved road is washed away, and the roads look like meteors crashed everywhere. Work and life doesn't stop because of the rainy season...we keep chugging along! Monrovia receives the most rainfall compared to any capital city in the world. Liberia, being the last vestige of the West African rain forest, receives an incredible amount of rain. I have lived in tropical countries before, but I have never experienced this kind of rain. Imagine a heavy downpour for 9 days NONSTOP! Not even a short beak, it pours incessantly for days at a time. And it is not even a drizzle, it is serious downpour. In one week, the paint on buildings washes away, shanty towns collapse and submerge in water, and you feel like you are going to be washed away in to the sea. It is beautifully cathartic in a way...the incessant rain washing away everything in its way.

The latest trip was particularly painful. It took us 14 hours to travel 250 miles. Thank goodness for Toyota! We would never get anywhere if it isn't for these trusty Land Rovers. Besides getting stuck in 6 foot deep mud pits, we had to wait for the trucks to pull themselves out of the mud so we can keep going. I am posting a few pictures that show the road condition. Look at that mud pit! A car dropped in to the pit just before us and it was struggling to get out...that's the smoke you see in the picture.

Despite these road conditions, people still travel in the interior. They have to, in order to sell their goods, produce, livestock. Note the goats and chickens sitting on top of a truck in the picture below. The truck was waiting along with us for clearance because the van in front of it is stuck in the mud.

Note that the goats are sitting on top of a hospital vehicle. Isn't that funny? Here is a close up of the goats waiting patiently on top of the same hospital vehicle. Can you tell I like goats? Of course, this picture is not for the PETA-loving folks!

Goats

How does Dr. V manage through this mess? Well, stylishly of course! Look at me waiting for a truck to clear itself out of the mud... what's going on with my hair in this picture?

ME!

However, this stylishness disappears once I get in the mud and start digging our trusty Land Rover out of a mud pit in a heavy downpour at 9pm in the middle of the jungle. Yeah, that happened last month! I took off my pants, jumped in to rain gear and started digging along with my driver. What else are we going to do, sit there and wait until someone appears and pulls us out? That could take all night! We took matters in to our own hands and got out of that pit. Sorry, no pictures of that incident. No picture taking when you are covered in mud and soaking wet from the rain. I looked like I am having a mud wrap, not in a fancy spa but the Liberian jungle.

At times we wait for hours because the vehicles in front of us get stuck and there is no way to pass. Two weeks ago (before the fateful tear gas incident), I went to Voinjama. It is a town on the far north end of Liberia, about 10 miles from Guinea. In fact, most people in Voinjama buy their goods at the markets in Guinea because of proximity. It took us 14 hours to get to Voinjama with only pit stops. On the way back we got stuck behind a truck that was carrying people and goods from Guinea. As with most transport in West Africa, it was carrying more than it could/ should. Combine the load with the road conditions in Liberia and you have a disaster. The truck got stuck in the mud and all the people traveling on top of the goods got off and started pushing. See picture below.

Truck stuck in the mud

Now you may wonder why the truck is so deep in to the road. Well, the truck was so heavily loaded that it sank in to the mud and the revving only pushed it deeper in to the ground. The goods you see in the truck are after they unloaded almost half of the original load. Notice the bags of onion in front and white rice bags in the back?

Then there was another truck that was coming from the opposite side and got stuck next to this one, effectively blocking traffic on both sides.

Blocked traffic

While there is usually no upside to getting stuck behind a truck in the middle of the jungle, I managed to find one. One of the ladies traveling on top of the truck, who got off the truck because it is stuck, was going to the market to sell her "goods". Goods meaning jungle tortoises. LIVE!! I saw her sitting on the mud road hoping for the truck to clear so she can make some money by selling her tortoises. At first I didn't believe that they were live and then I noticed their little heads poking out to see what is going on. I jumped in joy and immediately bought all tortoises she had (only two). The locals eat them...they would have ended up on somebody's dinner plate. Instead, they are now at Coconut Plantation House #12, safe and sound. Michael named them Samson and Delilah without knowing which one is male/ female. We realized the next day we named them correctly when Samson was looking for love from Delilah (I will spare the details!).

My local staff tell me that both tortoises are at least 50 years old considering their size, color, and rings on the shells. They are the West African Hingeback tortoises. Here is a picture of Delilah peeking out of her shell. Samson is camera shy. They like walking around the house and hiding. Who knew tortoises are fast?!

Delilah

I have a feeling my internal organs are displaced from traveling on these horrible roads, but they all seem to be functioning well. So, that's it for now. I will give the tortoises a bath while you enjoy the pictures. 

How about some tear gas with that lunch?

As some of you know, I eat lunch at a cook shop (Liberian slang for a hole-in-the-wall place) called Lowise's bar and restaurant. I shouldn’t call Lowise’s a restaurant; it is more like a shack. Heck, it doesn’t even have electricity…you have to eat in dim light even when it is sunny outside because of inadequate windows. I guess it is Lowise’s idea of a romantic lunch during the depressing rainy season. Monrovia is usually dull and dreary in the rainy season. The unrelenting rain keeps most people indoors. Despite the rain, I walk over to Lowise's at least three times a week for lunch.

Because the rain is relentless and crippling, people pour in to the streets as soon as the rain stops, even if it is for a few minutes. I am one of those people. On Friday, I walk over to Lowise’s to have some fried greens with fish and rice. I am savoring my lunch while I notice loud noises coming from outside. Now mind you, this is Monrovia, it is loud all the time. However, the loud police sirens alerted me. I got up from my unfinished lunch and walked over the entrance of Lowise’s to see what is going on. I notice police in full riot gear gathering right outside Lowise’s. I am usually unperturbed by these kind of activities, but this is Liberia; a simple demonstration can turn in to a violent life-threatening incident in a matter of few minutes. I ask the ladies serving food at Lowise’s what’s going on with the riot police. They say the Congress for Democratic Change (CDC) – the main opposition political party in Liberia – is holding a rally in protest of high unemployment rates in Liberia. Well, these kind of protests are common in many countries… it does not sound dangerous, does it?

Before I finish gathering information from the ladies, I hear people screaming from the outside and something similar to shots being fired. First instinct, duck for cover! Next thing I know there is thick smoke pouring in to Lowise’s. My eyes, nose, and throat immediately start burning. Then I realize it is tear gas. People are still screaming outside, running helter-skelter, while the ladies working in Lowise’s wrap their faces in cloth and lock the entrance door so nobody can enter from the outside.

So, here I am ducking under the table, with my eyes, nose, and throat severely burning, and no way to get out. I had nothing to cover myself and I was writhing in pain, wishing that this unprovoked tear gas attack will end fast. I waited under the table for what seemed like eternity, even though I think it may have been only 15 minutes, all the while coughing, crying, and suffering from the intense burning sensation. I call my boss while waiting and alert him to the incident. Since our office is just around the corner, he was able to witness the incident from his window, without having to inhale the tear gas like I did. After a while the ladies unlocked the door and I bolted back to my office (just around the corner). I washed my eyes and face with clean water and, like any crazy person who is addicted to work, went to a meeting.

I do not know the complete story behind the rally or the occasion for a protest by the CDC. However, from what I witnessed during lunch, the attack by riot police seems unnecessarily brutal. I saw a happy group of people singing and marching and the next thing I know the riot police are throwing tear gas at them. The sad part is that the tear gas attack happened about 100 feet away from a school. I can only imagine how terrified the children may have been. Such is the state of ruling political parties in many countries, they use brute force on opposition, sometimes without provocation. 

So, there you go folks…that was my Friday afternoon. A little tear gas served with my lunch. How did you spend your Friday?

Hello neighbor!

It's been a long time since I've posted anything. July has been hectic, to say the least. Between finalizing plans to build capacity and strengthen the health system in Liberia, digging myself out of mud roads in the jungle, and planning a short holiday in France, I was swamped. In the middle of all this hoopla, I managed to visit our neighbor - Cote d'Ivoire.

Ivory Coast, as it is know to primarily English speakers, is a sea of change from Liberia. And I mean that in a positive way. From the people to the food, I loved everything about the country. I managed to visit four places - Abidjan, Yamoussoukro, Grand Bassam, and Assinie. I felt like being in a paradise compared to Liberia.

My friends know I have been in Liberia for 7 months now. I have not once left the country. This is unusual and very difficult for someone who used to fly at least once a month for something or another. Liberia takes its toll on you. It has been work, work, and more work...with no respite. I haven't had a full 2 day weekend since February. As much as I enjoy being busy (and I LOVE my work), I was getting to a point where I needed a short break.

Enter Cote d'Ivoire. Neighbor and savior! Just a one hour flight from Monrovia lies a completely different city called Abidjan. Where there are 6 lane highways, skyscrapers, and excellent restaurants. People are friendly (even to those like me who speak broken French), and the concept of customer service exists. Heck, they even have shopping malls in Abidjan which accept credit cards. Imagine my joy when I swiped my card after 7 months. I missed shopping. Sigh!

There are so many nice things I can say about Cote d'Ivoire. First, the people. There is a sense of community in the country. Random people talk to each other on the streets and ask how you are doing. Yes, there is corruption, but the corruption is not as abrasive and aggressive as I've seen in Liberia. It is done in a more sophisticated fashion, if there is such a thing as sophisticated corruption!

I hired a car service recommended by the deputy director of USAID mission in Abidjan, who also happens to be a friend. It turned out to be a great decision, because of the language barrier. I didn't have to worry about my broken French because my driver did most of the translation for me. This arrangement enabled me to eat delicious local food without worrying about translations. I ate plenty of attieke, poisson braise, kedjenou, and fatou. Three weeks since my trips to Abidjan and I still miss poisson braise Ivorien. Fish (carp or perch) braised in herbs, onions, and tomatoes, it is simply delicious. Recipe here. Attieke (cassava couscous) turned out to be the perfect accompaniment for poisson braise. Here is a recipe for attieke with tomato-onion sauce, if you are interested. Kedjenou turned out to be another favorite of mine. Stewed chicken in spices and herbs, it is a delicious dish.

Kedjenou and attieke

Then there was agouti stewed in a bitter eggplant sauce. Agouti, also known as "rat de brousse" in French, is basically a bush rat. It is also known as groundhog, or grass cutter if you are in Liberia. While devouring the dish I realized I am eating a giant rat. Oh well, a tasty rat! Lastly, but certainly not the least, I had sauce djoumble. It is the Ivorian version of gumbo...dried okra helps thicken the sauce. Although it is usually served with fish, I had it with pintade (Guinea fowl). One of my guilty pleasures is fried food. You have no idea how happy I was when I found fried donut-like items in Abidjan. Even better, it was street food. The only thing that makes friend food better is when it made on the street in a busy market. Look at the woman making the donuts in the Adjame market...doesn't it look tasty?

Deep fried dough in the Adjame market

I devoured the wami (sp?) like a famished person. Deep friend millet dough never tasted so good!!

Wami (sp?)

I talk about food often. To me, food is a top indicator of a culture. I prefer to experience a culture first hand through food. A complex and delicious cuisine is an indicator of a rich and intriguing culture. At least that's my theory and I am sticking to it. If the local cuisine of Cote d'Ivoire is any indication, it is a highly cultured society.

One of the highlights of Abidjan is the zoo. Granted it is in a sad state after the recent civil war, but I was thrilled to see a few animals....particularly, Marguerite the pygmy hippo. I also hand fed an elephant, watched a baboon expose itself to me in a sexually grotesque manner, and met the 150 year old giant tortoise that traveled from Sierra Leone zoo to Abidjan zoo. Feel free to browse through my pictures (click the picture below for a slideshow) or click here for the complete album.




I also visited Yamoussoukro, the capital of Cote d'Ivoire. I did a day trip to Yamoussoukro with the expert driving of Marcellin, my driver. The roads of Cote d'Ivoire, unlike the roads of Liberia, enable you to drive 300km in under 3 hours. The same distance takes me 7 hours in Liberia. Crocodiles, cacao trees, coffee plantations, papaya plantations and loads of fun. I visited President Houphouet-Boigny's mansion, his private crocodile lake, and all the huge crocodiles that live in the lake.

In Yamoussoukro I visited the Basilica of our Lady of Peace. Listed in the Guinness Book of World records as the largest church in the world, larger than the St. Peter's Basilica in the Vatican, the Basilica or Our Lady of Peace was built between 1985 and 1989 with a budget of US$ 300million. It is a reminder of the glorious times of Cote d'Ivoire, when the country was stable with a booming economy. I did not like the Basilica. It is a large and grotesque structure with no character. It feels like the architect and the government wanted to construct something to attract world's attention and did not care about the aesthetics. It feels very sterile and plastic to be inside this mammoth structure. I even ate ripe coffee fruits. Yummy! Check out my Yamoussoukro picture album.  The highlight of my trip to Yamoussoukro was visiting the cacao and coffee plantations (see album link for pics).

My crocodile friends, just relaxing in the president's private lake!

A day after Yamoussoukro, I visited Grand Bassam and Assinie. Grand Bassam was the first capital of Cote d'Ivoire. There is a lot of history associated with Bassam from French colonial times. The museum director opened the museum exclusively for me, even though they were closed on that particular day. I got my own private showing of the culture and tribes of Cote d'Ivoire. Splendid!

Assinie (pictures here) is what I like to call "the Hamptons of Cote d'Ivoire". Beautiful mansions on the beach, lovely restaurants, and the playground of the Ivorian elite, Assinie is definitely a place to relax and have fun. The beach is beautiful, the food is stellar, and the people are friendly. A perfect vacation spot if you ask me. Perhaps I will go back and rent one of those beautiful beach mansions for a weekend.

Assinie

After five glorious days in Cote d'Ivoire it was time to come home. The only disappointment I have is that Abidjan is so close (only a one hour flight), yet it is impossible to go just for a weekend. The flight schedule is not helpful to take weekend trips. Perhaps that is a good thing...because I would spend every other weekend in Abidjan if the flight schedule was enabling. I look forward to returning soon.

When the clouds come rolling in...

Last week I traveled to Sanniquellie for two reasons. One was to conduct a workshop for the health workers on using data for making decisions. The other reason was to explore why contraceptive use is very low in Nimba County. I will write about those two parts later, I have to talk about the drive to Sanniquellie.

The better part of the road - with few potholes and washed away at its seams

I like driving up country, or as the Liberians call it, "the bush". The drive from Monrovia to Sanniquellie is quite the feat, because of the road. I haven't been to Sanniquellie in a month, so I wasn't aware of the condition of roads. The terrain changes rapidly in the rainy season, because it doesn't just rain here. The rain in Liberia is unlike any other. It is powerful enough to wash away everything in its path. To give you an idea, Liberia received the third largest rainfall in the world, for its land area. Monrovia is the city with the highest rainfall in the world. Since the rainy season started a month ago, I wasn't quite sure what lay ahead in front of us. Well, not much lay ahead. The dirt road that has washed away in most areas leaving huge potholes the size of craters, and rocks. Part of the road is paved. the part from Monrovia to Gbarnga is not bad, the part from Gbarnga to Ganta is the worst, and from Ganta to Sanniquellie is just track. Half of our journey is spent clinging on to our dear lives on the hand railing in our Land Cruiser. I do not recommend anyone with a bad back doing this trip.

However, not all is bad. The scenery is beautiful. That's what happens when you drive through the last remaining rain forest in West Africa. Lush tropical forest lines either sides of the road. Huge rubber trees stand majestically among the underbrush. The Liberian rain forest is also the world's only known habitat for pygmy hippos. I haven't seen one in the wild so far, because they are rare, shy, and highly endangered.

Since it is the rainy season, and these are no ordinary rains, you always are caught in a downpour. The sight of a rain storm rolling in always enthralls me. The colors - green luscious forest, red dirt road, the blue sky, and black clouds rolling in with immense speed - is quite the sight to see. Although I am no professional photographer, I tried to capture some of the intense beauty with my simple yet trusty Canon Powershot.

The clouds roll in...

What you see on the right is a small hamlet, three huts bordered by plantain and coconut trees. I asked our driver to stop in the middle of the track so I can marvel at the beauty of nature. I started taking pictures and a man came out of one of the huts to see what we were doing. After some more picture taking, we resumed our bumpy journey.

The dark sky and darker road

As we pass through more forest and start driving through the heavy downpour, we are greeted with various sounds from the forest, people running to their huts to avoid the rain, and, my most favorite of all, the smell of  earth when it receives rain. After about an hour of driving, we finally get past the rain, and start watching for the huge puddles on the road. It is a good thing we have the trust Land Cruiser, you cannot do this drive with many SUVs.

One of the things you have to be cautious of this rain is the huge puddles that form in the road. It is difficult to  avoid and gauge the depth of these puddles, which leads to many accidents. These are no ordinary puddles, they can swallow half of your car easily. We witnessed one such accident. A semi-truck that got stuck in one such puddle because it was too deep. The semi kinda nosedived in to one puddle while avoiding another puddle. Luckily there were no casualties, just a semi stuck on the road. This does not bode well for us, because you cannot take a diversion.

Accident!

Now, you may wonder why there is a big semi in the middle of the rain forest? It is because one of the largest iron ore mines in Africa is located near the Liberia-Guinea border, in a town called Yekepa. You have to pass through the rain forest to reach Yekepa. Arcelor Mittal has a huge mining operation going on in Yekepa, and this particular truck was delivering some supplies to the mine.

We got out of our SUV, walked around to see if there is any clearing on the side of the road and decided to take a chance with off-roading. There is no way we are staying stuck in the forest behind this semi, while it is getting dark. Look at my boss and our driver surveying the terrain.

My boss and driver surveying the terrain before deciding if we can off-road

My boss drove Land Cruisers in the rain forests of Cameroon 30 years ago, while volunteering as a physician in the jungles of Cameroon and Congo. He has worked extensively in Africa and he has a great knowledge of the terrain. With his and our trusty driver's skills, we were able to get out of this road block. Look at our intern waiting patiently and watching the scene.

Heather waits patiently while enjoying the scenery

That's our trusty Land Cruiser, by the way. Almost all international donors and NGOs working in Liberia have white vehicles. The rhino horn looking thing in front of the car is for our satellite phone, if we get stuck in the jungle and need the American government to come get us :) After some maneuvering, we were able to get on the road and resume our journey. We got out to see the accident from the front and it looked like this...

The accident from the front

Well, that crash could have easily been us. But we have skilled drivers, so I rarely get worried about driving through the rain forest. Just look at that lush greenery on either sides of the road. Stunning!

We go on with our journey and arrived at Sanniquellie safely. Finished work in two days and came back to Monrovia. I bought a big bag of palm nuts for Isaiah on the way back home. He is one happy bird!

Birthday celebration in Liberia

On Monday, May 21, I turned another year older. Not any wiser, mind you!

In a country severely lacking in fun things to do, how does one celebrate a birthday? Or any special occasion? Well, you adapt to the local situation and make it simple. I still tried to make the best of it with the help of family.

The day before my birthday, I received the best gift. A coffee maker!! I know, I know! You all probably think what's so special about a coffee maker? Well, let me tell you what makes it special. There is no such thing as decent coffee in this entire country. People here drink instant coffee. If you are someone like me, who is used to living on 8-10 shots of espresso per day and a gallon of coffee, you will find this country absolutely horrid. In my knowledge, there is only one place in the entire country that serves filter coffee and espresso. And that depends on the day. Some days they don't have either. Sometimes it feels like it is easier to obtain blood diamonds and illegal wildlife than finding a decent cup of coffee. So, imagine my joy when I received a coffee maker! I was so thrilled that I thought of sleeping next to it in the kitchen.

On the day of my birthday, in stereotypical Indian tradition, I arranged a party for my colleagues. Americans usually do it the other way around, but we Indians see it as our responsibility to feed people who have come to wish you. So, I arranged for lunch. Potato greens and rice...the quintessential Liberian dish. It also happens to be my favorite Liberian food. We took a group picture before lunch.

Group hug! Look at me in green!!

After eating a bucket load of potato greens with rice, I had to be wheeled out of the conference room in to my office. My gluttonous self was already thinking about dinner. We went to one of the "fancy" places in town, and there is a reason why I put the word fancy in quotes. It is one of the few places in town where you can get somewhat reliable service and good food, besides cocktails. Barracuda Sushi Bar is housed in the famous Mamba Point Hotel, within walking distance to our house. The sushi is good, the ambiance is pleasant, and they have limited cocktails.

After coming home from dinner, I received the second birthday present. Although I am unable to see it in person, I am most excited for it. It is a Heidi Norton sculpture. The artist will be shown at the Chicago Museum of Contemporary Art starting August. The sculpture I/we own is listed on her website, but I am posting a picture here as well. It is a mixed media + live object sculpture, with a living fern and other objects encased in resin. Even though I haven't seen it live, I am absolutely fascinated by it. I cannot wait until I return to the US and see it in our home.

Heidi Norton sculpture

Despite living in Liberia away from most of my friends and family, I managed to have a wonderful celebration because of one person. At the end of the day, all that matters is that we are together.

The first and only comprehensive assessment of capacity of the health system in Liberia - finally!!

Capacity building seems to be the buzz term in Liberia. Everybody and their mother talks about building capacity! I am not even joking when I say everyone from the international donor community to local pen-pen drivers use the term capacity building. Sometimes it feels like people are just using the term because it makes them look "cool". Almost every NGO and donor agency has a line item for capacity building in their work plan. There is even a national capacity building strategy document for Liberia. If I had a nickel for every time someone used the term capacity building! Don't get me wrong! I strongly believe in building capacity. However, I get frustrated sometimes because the term is used very loosely. Many people who are in the business of building capacity in Liberia see it from a very narrow point - the point being training individuals to build workforce capacity. For someone like me who has spent a majority of his professional life strengthening systems, it is a bothersome view. Training workforce is one of the three components of capacity building; it should not be the only focus. An individual functions well in a system that enables her/ him to put their skills to good use. You cannot just train individuals and leave them to work in a system that is not conducive to working efficiently and effectively. Strengthening individual capacity and system has to happen simultaneously if we want to achieve maximum results. Allow me to give you an example. We often hear people being trained in Monitoring and Evaluation (also known as M&E for the geeks in international aid community). I personally know plenty of local workforce that has been trained in M&E as a part of building their capacity. However, the system under which an M&E professional works is not always enabling them to use their training. How can a trained M&E person be productive when s/he is lacking a data collection and reporting system? What kind of functions will a trained person perform when they do not even have a job description? What kind of data analysis can be performed and how is the data used towards decision making when there is no mechanism/ system to analyse data and distribute the findings to key stakeholders? The above example is just one of the numerous instances where a narrow focus on capacity building does not yield intended results. More often than not the NGO and donor community tends to focus narrowly and not see the big picture. While there are situations where a focus on individual capacity takes precedence, one must always keep the institutional and systems perspectives in mind. For example, immediately following conflict there was a great need for qualified workforce in Liberia. Majority of the resources were focused on building workforce capacity, which, at that time, was thoroughly justified. Now that foreign aid is dwindling and Liberia is moving in to a phase of planning for sustainability, the time is ripe for building comprehensive capacity, not just individual capacity. That is exactly why my/ our project's approach towards building capacity is comprehensive. The approach is comprehensive; I/we focus on three levels of building capacity - individual, organization, and system.

A notice pinned on the main notice board of Lofa County Health System announcing our assessment and  "mandating" participation

As mentioned in one of my previous posts, I am following the WHO six building blocks of a health system framework. There are two reasons for this: 1. The Liberian National Health and Social Welfare Policy and Plan (NHSWPP) is designed around the same framework 2. The framework is flexible enough to adapt to various situations and country systems and allows us to assess the health system in a comprehensive manner.

For anyone who has ever designed/ conducted/ participated in a health system assessment, I do not have to reiterate the fact that it is an extremely tedious process. As tedious - and sometimes frustrating - as it might be, it is immensely satisfying for geeks like me. It is very rare that an entire system comes together to assess performance, capacity, and functions. We finished the county level assessments two weeks ago and we just wrapped up our central assessments.

Key respondents and staff conducting the assessment in Lofa County

The county assessments were conducted in three counties - Lofa, Nimba, and Bong. They took place over a period of two weeks - two days for each county assessment + travel time in between. A team of us - from the ministry and our project - traveled to each county to conduct the assessments. I am not ready to share the results of all assessments yet, but I will say there is a lot of work to be done. No surprise there!

We are now moving in to the phase of analyzing our data and writing a report about our findings. I can already tell there are a few areas that we need to focus - performance management, pharmaceutical supply chain management, data use for evidence-based decision making, and organizational restructuring. The last one is going to be interesting to pull off, because people are usually resistant to change, especially when it comes to restructuring. There is vast disconnect between what the central ministry perceived the capacity to be at the county level and the actual capacity. We need to address this disconnect if we have to move forward with strengthening the health system.

I always seek feedback from respondents immediately following an assessment. One of the statements that gives me satisfaction and makes it all worth is when the respondents said (I am paraphrasing here) "many people have come and gone in the name of capacity building assessments...you are the first person who has approached it comprehensively and has a plan". I will share the results once we finalize the report with feedback from the ministry. Until then, I am going to be spending numerous late nights writing the results and a plan of action.

I promise I will write something fun in the next post...food or about animals :)

War stories

Last week the international court in Hague delivered a guilty verdict in the Charles Taylor trial. It was a somber mood in the office all day. Like most days a few of us gathered around the dining table in our kitchen to eat lunch and chatter. However, April 26 was not like any other day. Almost every Liberian who works in our office has been through the civil war in one way or another. One of my colleagues started discussing the verdict and the conversation snow balled. Then came the war stories. Oh the stories!!

There are countless stories from Liberian civil war. Almost everyone you meet on the street has a story about their experience during the war. However, you don't really hear them unless you ask. And if you are like me, you do not ask strangers to speak about their suffering - past or present - unless they initiate such conversation. That is probably why I do not have as many stories as reporters or researchers. But I am quick to make friends with co-workers. Even though most of my Liberian co-workers left at the onset of war, there are a few who didn't leave until late, or didn't leave at all. I do not ask their experiences during the war because I think it is rude to be inquisitive about suffering. While having lunch yesterday, two of my Liberian colleagues started talking to each other about their experiences during the war that made my jaw drop. I don't usually like to talk about suffering, but two of these stories demonstrate determination of women in the face of adversity. Allow me to explain without going in to many details, in order to protect privacy.

One of my colleagues was 9 years old when the war started in the last week of 1989. Her father was afraid for his six daughters because the rebels were taking girls and women away in forced concubinage. The rebels usually demanded food and women. Her father hid his daughters whenever rebels were in town. He gave away most of his belongings, including his livelihood (a car - he drove a taxi), in order to save his daughters from the rebels. Every time a rebel group came knocking he would give away something to divert their attention from his children. Like most poor Liberians, he quickly ran out of things to give to placate the rebels. That's when he decided to send his daughters away. He split them in to two groups, so at least few would survive. He took one group, his wife took the other group. My colleague happened to be in the group with her mother. They traveled through the rain forest and military checkpoints, fleeing the rebels, going from one town to another, Guinea being their final destination. My colleague's sister (one of the six daughters) was a new mother with a 6 month old child. They were carrying the infant along with them. At one of the checkpoints, while waiting clearance, gun fire erupts and everyone is displaced running for life. In this melee, my colleague who is carrying the infant is separated from her mother and sister. Not knowing what to do, she runs with another group of people fleeing the gun fire while carrying the infant. My colleague was 10 years old at this time and even though she did not know what motherhood means, she knew how to take care of an infant. However, she didn't have anything to feed the baby. After fleeing the commotion, she joins another group of refugees and hides in the jungle. The group is hiding quietly so the rebels won't catch them and that's when the baby starts crying. In the words of my colleague, she has no milk in her breasts to feed the baby. That's when one of the women in the group came over and put her breast in the infant's mouth so he would stop crying. To quote my colleague directly "she put her titty in my nephew's mouth". She did this so the baby would be quiet and they would go unnoticed. Imagine a 10 year old fearing for life while another woman is breast feeding her nephew. I cannot even come close to imagining her situation.

After hiding in the bush (Liberian word for forest) for many hours and realizing the rebels left, the group emerges and starts looking for others who ran in different directions. My colleague was able to find her mother, but they never found her sister (mother of the infant). The two of them and the infant traveled for many days, hiding in the jungle at times to escape from rebels, and finally reached Guinea. All this while the infant was being breast fed by other women who were fleeing along with them. When they finally crossed the border in to Guinea, the UN sent a a truck to transport Liberian refugees from the border to refugee camps inside Guinea. However, most of the refugees, including my colleague, were too weak to be transported. That's when the UN set up tents right near the border to accommodate refugees.

I never asked what happened to the rest of her family.

Orphaned children during the Liiberian civil war. Picture courtesy of the Daily Beast

The second story involves another colleague's friend. Although my colleague left at the very beginning of the war, her friend was not lucky to do so. The story will be gruesome to many of my friends who read my blog, so I will refrain from details. But I will say this: women like her deserve a special place in heaven for saving young girls from being raped and killed by rebels. How many women you know will offer their body to rebels in exchange for the life of a few young girls? It is amazing to listen what ordinary citizens can do when confronted with brutality.

Again, I never asked what happened to my colleague's friend and the girls she saved on that particular day. Some questions should be left unasked.

I feel it is the women and children that suffer the most during (and after) war. I think if any war mongers see the suffering encountered by women and children there will never be a war in this world. But then, it means war mongers are capable of rational thinking and emotions. We all know that is far from truth. I salute women everywhere who are courageous and kind, who can rule nations and nurture families and who are infinitely stronger than men in many situations.

In spite of all the atrocities, Charles Taylor still enjoys a following among some Liberians. In fact, some locals say he will be elected next President if he is freed from prison. It makes one wonder how someone like him can still enjoy support. Many unemployed former child soldiers still hold Charles Taylor in high regard. They call him "Papay" or "Papa Ghankay". Ghankay was a name Taylor adopted during the war in order to appeal to the indigenous tribes. Most of these ex-combatants were orphans who were recruited by Taylor's faction during the war. They see him as a father figure for giving them food to eat and a gun to fight.  It is normal human tendency to revere the hand that feeds you when you are starving.

Liberians holding a rally in support of Charles Taylor. Pic courtsey of GlobalPost

The civil war was a consequence of various complex factors. It is not possible to explain those factors in one blog post. There have been plenty of articles and books written on the civil war, but many of them do not look at the Liberian perspective. More often than not it is some western journalist or author writing about the war from their own perspective. One book that I read which explains the complex factors in detail is The Mask of Anarchy. I encourage my friends and readers to read it.

There is a great poem by Percy Bysshe Shelly titled The Masque of Anarchy that is worth quoting here. The poem was written in 1819 on the occasion of the Peterloo Massacre at Manchester, but it is quite relevant in the Liberian civil war context. I came across this poem while reading The Mask of Anarchy, the book I mentioned earlier. I will only quote the last stanza because it is the most relevant here.

"Rise like Lions after slumber

In unvanquishable number -

Shake your chains to earth like dew

Which in sleep had fallen on you -

Ye are many - they are few."

Humankind eventually rises against oppression. That hope is what keeps us alive.

How to transport goats?

On a pen-pen, naturally! Duh!!

Over the weekend I traveled to Buchanan - capital of Grand Bassa County - to assess the state of the county health services and system. It is only a 2.5 hour drive from Monrovia, so I left on a Sunday afternoon (after a great buffet lunch at the Royal Hotel...something to talk about another time) around 3PM to arrive in time. On our way we discover that a road construction company is blasting a hill to make way for the road. We stopped and waited for the blasting to be finished so we can keep driving without being hit by flying rocks. While waiting for the blasting to be finished, I got out of the vehicle to walk around (there was a river nearby). Many people were waiting with us and I noticed a lot of motorbikes and some cars behind us.

While walking towards the river I hear sounds. I immediately recognize it is a goat, and I was excited to see one out in the wild. I was disappointed to see that the goats were actually being transported on a pen-pen (Liberian word for motorbike).

Goat mobile

As cruel as it looks in the pics, I have to tip my hat to whoever came up with that contraption to hold the goats. It fits perfectly on the back of a pen-pen and it had THREE goats in that small contraption. Notice the guy grinning wide while I am taking pictures. He seems to be proud of this invention.

Three goats on the back of a pen-pen

While some guys are innovative in transporting animals, others are just plain lazy. The following picture shows a goat with its legs tied and transported on the back of a pen-pen by two guys. It seems to be happy sitting in the back seat in between two people.

Lazy goat mobile

After a short drive we arrive in Buchanan only to realize that the situation in town is tense. Allow me to explain. There was a maternal death in the county hospital few days before our visit. The woman's family claims it is due to medical error, the county hospital claims the woman died because her family did not bring her to the hospital in time. My understanding - with the limited information I received on site - is that it was a case of obstructed labor due to breech presentation that was not attended promptly. Regardless of who is at fault, the woman and fetus did not survive. The family is now up in arms against the hospital and issued a threat to kill all doctors and health workers at the county hospital. And here I am, a physician, arriving at the county hospital in a vehicle that a has a huge logo of our project. Its like saying "look at me, look at me, I am a doctor". The County Health Officer and most of the health workers fled town fearing for their life. Needless to say I got back in the vehicle and requested my driver to take me back to Monrovia immediately. We have a policy of not driving after dark, but I didn't feel safe staying in that town for an extra minute considering the tense situation. We got back to Monrovia safely around 9PM.

So, that's my dramatic trip to Buchanan. Even though I didn't get to do my work, I am happy to have witnessed the "goat mobile".

Service delivery in the bush

Two weeks ago I visited some of our health facilities in the Grand Cape Mount county to observe service delivery and organizational structure. Our project supports many health facilities across the country, I am trying to visit as many as I can. As part of this mission, I visited one health center and two clinics - Sinje health center,  Bo-Waterside Clinic, and Tieni Clinic. Terminology is important because a health center is different from a clinic - type of services, number of staff, catchment population, and other factors play a role in deciding if a particular facility is a health center vs. clinic.

Sinje is a health center. They have a maternal and child health ward, provide family planning and reproductive health services, and even have an in-patient section. Fairly well run. I found a few issues here and there, but what health facility does not have issues, especially in the developing world? Even though I am not their supervisor, I found some areas in health records maintenance that I advised. I noticed that the newly appointed child survival officer was not adequately trained on recording patient data, therefore I took it upon myself to show her what individual columns mean in the ledger and how to record patient data. She was more than happy to listen because she has been looking for someone to show her how to record some of the data. If you look at the size of the book (see pic below), you will realize why training is needed to fill in the data. Our County Coordinator was quick to capture Dr. V in action, resulting in this picture.

Me explaining data collection to the child survival officer. Look at the size of that book!

After visiting the children's ward and talking to various staff, I wanted to visit the maternal health section. Reproductive and family planning services are top priority when it comes to improving Liberian health system. As such, it is very important for us to understand and improve service delivery in these areas. I was greeted by the Certified Midwife, who just finished delivering twins. I had the privilege to visit the children and delivery room. Neatly maintained. I even spoke to a few pregnant women who were waiting for their antenatal care checkup. I inquired patients about their satisfaction with services and the type of services they are receiving. While services are delivered as planned, there is still a lot of room for improvement. That is why I am here, to strengthen service delivery as a part of strengthening the system.

Avoid sex?

One of the posters I noticed on the wall in the maternal section caught my eye. It is a message aimed towards youth. Teenage pregnancy is a big problem in Liberia and there are different campaigns - from USAID, EU, WHO, etc - aimed towards family planning of both youth and adults. This particular poster is not from our project. What particularly caught my attention on the poster is "avoid sex". Technically speaking, the poster is absolutely correct. Abstinence is part of comprehensive family planning. I appreciate the "protect yourself at all times" message.

Following Sinje, I visited Bo-Waterside clinic. Also known as Bo-H2O (waterside = H2O, get it?), the town borders Sierra Leone. We ate lunch at a restaurant situated right at the border. In fact, we waved at the border patrol while eating lunch. Bo-H2O delivers a limited range of services compared to Sinje health center. We talked for an hour with the Officer in charge (OIC), who is a young guy working there for about 6 months. I discovered a lot of issues with the way the system is currently set up and I plan to address them during our interventions. Tieni clinic was the same as Bo-H2O, with limited service delivery and an even smaller facility. 

Pink delivery table

Besides these facilities, I also visited the Gbanway clinic in Lofa County. One of the best clinics I've visited so far, very clean, neatly organized, and all staff were present and busy working on the day I went (I didn't inform them ahead of time of my visit). The major attraction at Gbanway clinic is the pink delivery table. It put a smile on my face. Child birth is a tedious process, a little color in the delivery room might add some pleasant visual. I am so tired of seeing the hospital green and grey delivery tables, pink is a welcome change. I think every clinic should get a pink delivery table.

I can write about each one of the clinics in great detail, but I do not want to bore my non-public health friends with additional details. I have more trips planned and I will post pictures of my visits. I am in the bush all week doing assessments, so I hope to come back with more stories and pictures. 

Professor Moominpappa

Last week was the most professionally fulfilling week since I've been here. Don't get me wrong, I love my job, despite the drama and frustrations. But work is all I was doing since landing in Monrovia more than 3 months ago. I have accomplished a lot (according to USAID), and still felt I am not doing enough for Liberia. Well, now I don't feel lacking anymore.

Some of my friends know I like teaching. I was guest lecturing and assisting my friend/ colleague Christina in teaching a Masters level public health course at UIC before coming to Liberia. I never imagined myself being a professor (even a assistant or associate professor), but I enjoy teaching. Two weeks ago I mentioned to our Chief of Party (COP) that I miss teaching. Our COP is an Americo-Liberian woman, she was a practicing pediatrician in Monrovia before leaving the country many years ago. Besides running the largest US government health project in Liberia, she also teaches at the local university. A day after I mentioned to her that I miss teaching, she asks if I would like to give a guest lecture in her class. Imagine my joy when I resoundingly said yes!

Last week was my guest lecture. I was taken to Cuttington University by our COP. You should see the looks I got when she introduced me as the guest lecturer. I guess the students were expecting someone around our COP's age, not a young(er) professional. However, they were all eager to listen to what I had to say. I was surprised to find one of my staff members in the class. Even though I am her supervisor, I haven't been able to connect much with her (outside of work) because of our schedules. She commented "you are my supervisor and now you are my instructor as well". I hope that's not a bad thing!

Students work in teams to identify risk factors for health problems

The course that our COP teaches is titled "Primary Health". A perfect conduit to teach about public health. Since I don't believe in lecturing for more than 30 minutes, I made a short power point presentation. I then gave an exercise to work that lasted for an hour. I split the class in to teams and each team worked on identifying risk factors for a different health problem. I admire the tenacity of the students. Imagine sitting in a room with no air/ fan in a 100F humid temperature for 2-3 hours for each course. Some of them do it all day when they have back to back classes. I was soaked in sweat within the first 15 minutes of my lecture, I can only imagine how these students do it every day. I took encouragement from the students and kept on with the lecture even though I was dripping buckets of sweat. These students are my inspiration.

The students thoroughly enjoyed the exercise. Each team had arguments and discussions, but they all came to consensus in the end. In fact, when I asked what's the most important lesson of this exercise, their answer was "team work". You have no idea how happy that made me. We all know how important it is to work in teams, but team work has an added significance in a country like Liberia that has been torn apart due to internal differences. They really need team work here, at all levels.

More student teams working on the exercise

I think the best sign of a successful lecture is when students ask you to come back. At the end of the class, when I asked if they have any questions, they all said "we hope you come back!". Yes students, I will be back. I will definitely be back now that I have found my favorite way to contribute to Liberia outside work. Just call me Professor Moominpappa and I will be at your service!

Trips to the "bush" and cow meat soup

You cannot rebuild a health system sitting at the central ministry in the capital (Monrovia), you gotta travel out and see what's going on in the interior. In my quest to explore the state of affairs in the counties and villages, I travel often. One such trip was to Lofa County. The capital of Lofa is Voinjama, a small town quite far from Monrovia. Located only a few minutes from the Liberia-Guinea border, Voinjama is a small but busy town in the middle of the jungle. It took us 8 hours to get there, mainly because of bad road conditions... and that's during the dry season. It takes longer once the rainy season starts. Sometimes we stop in one of the towns on the way, stay overnight, and continue the next day. The road is paved only till Gbarnga (3 hours north west of Monrovia), and then it is dirt road. The local slang for all villages is "bush". Locals say "bah! you gone to the bush?". "Bah" is a term of endearment, meaning friend. Liberian English is a language of its own, with varying dialects and pronunciation. I have to switch gears between the drivers, my staff, and the housekeeper. One of my staff even speaks a mixture of English and Mano (a local language), making it difficult for me to understand what he is saying. But, I have gotten better at it. I now understand 75% of what he says, it used to be 20%.

The paved road is nothing to talk about, just an old road that is ridden with pot holes. I wonder if some of the potholes are from the heavy rains or remnants of bombings during the civil war. I do not recommend anyone with back problems travel on these roads, you will need spinal surgery after a few trips. It is interesting to watch our drivers maneuver through these huge pot holes... most of the times we end up off-roading while I cling on to my dear life by holding on to the railing in our Land Cruiser. I pity all our vehicles, they take such beating when we go to the bush. The dirt road, on the other hand, is a beauty. The soil in Liberia is very fertile with a red hue, almost rust-like. Our white vehicles return looking rust-colored after every trip. It is quite beautiful driving on a red dirt road surrounded by thick green jungle interrupted by rivers and streams with the occasional goat or monkey jumping on to the road... it almost looks like a painting.

The red dirt road to Voinjama

The soil is so fertile that villagers have to burn the brush so it doesn't grow back within days. Cutting the brush won't do, you gotta burn in to the ground. Even then, new sprouts arise within days. A mixture of perfect tropical weather for vegetation, heavy rains, and fertile soil makes Liberia a heaven for plan growth. Unfortunately, this natural resource has not been  harvested to grow food for the population. Prior to the war, Liberia used to export rice, now 85% of food is imported. Various international organizations are helping rebuild the agriculture infrastructure.

Before going on one of my trips to the bush I was informed of a restaurant in Gbarnga by fellow expats. Even my drivers sung high praises of this restaurant. I wanted to check it out and we stopped for lunch. They had only one dish that day - cow meat soup. That's how it is in the bush, people serve what they get on that particular day. Some days it is nothing. I always carry Clif bars with me because you never know if you will get food in the bush. Shout out to my pal Lissner who taught me the wonders of Clif bars. Even though he tried to get me to like the white chocolate macadamia flavor, I prefer the dark chocolate flavor. Anyway, I digress.

My staff and I sit down and order the only option we have. By this time, after two months of living in Liberia, I have come to accept the fact that it is normal to find mystery meat in your food. Liberians do not understand the concept of cooking or cuisine, they dump everything they can lay their hands on in a pot and cook it. As I talked in my previous posts, expect to find anything from feet, fat, and organs to meat, skin, and other unidentifiable parts of an animal. When in Rome...

We sit down and wait for our cow meat soup. The waitress assured me it is cow meat. That doesn't mean anything in Liberia. You always get a melange of animals regardless of what they tell you. So, here comes this cow meat soup. What Liberians call soup is actually stew. Looks like chunks of meat+fat floating in an oily stew. Fine, it is not any different from other stuff I've eaten. Remember my post about Lowise's restaurant and palm butter? Well, that was one of the many instances.

Cow meat soup - meat and other stuff swimming in oil

I dig in to my oily stew, scoop out a spoonful on the plate of rice that comes with the stew (everything comes with rice or fufu). Halfway through my meal I notice strands of short thick hair. Eh, this is nothing. At least it is not a dead roach. I pick the hair out of my food and continue eating while pondering where the hair came from. Then I receive the answer to my pondering. In the second spoonful, I notice a chunk of cow hair sticking to the skin. Ah, so this is not just cow meat soup, it is cow hair soup as well. The culprit is a piece of cow skin with a tuft of hair still attached to it. I look at it and wonder which part of the cow it came from? Is it the hump, the tail, leg, which part? Should I call it leather instead of skin because it has been cooked to death? Looking at the length of the hair, it could be the skin from a cow's tail or back. I am posting a picture of a smaller chunk of hair, because even I couldn't stomach the idea of taking a picture of the larger tuft of hair (yes, there were more than one chunks of hair). Notice the lone strand of hair on the side and a small tuft of hair sticking to a piece of skin, next to the rice.

Hair sticking to cow skin, a lone strand of cow hair, and a burnt matchstick - all in one spoonful

Then there was a burnt matchstick in my food. Oh well, at least I didn't get coal. I take out the piece of skin/leather with hair, the matchstick, and continue eating my soup. I am not going to stop a little tuft of cow hair and burnt match ruin my lunch. I may have eaten some strands of hair here and there, but my stomach can easily digest that. Hell, it has digested worse things, what's a little hair going to do? Three of us finish eating, pay our bill, and I left the tuft of cow hair on my plate. Nary a word from my staff. They noticed the chunk of hair, but it didn't bother them. I assumed from their reaction (or absence thereof) it is common to have animal hair in your food. Once again, when in Rome...

We finish lunch, continue on our journey to Voinjama with bellies filled with cow meat and hair soup. Once in Voinjama, I had the best food I've had since I moved to Liberia. I discovered the United Nations Pakistani battalion in Voinjama. They let outsiders eat in their "officers' canteen". I had the most amazing Pakistani/ Indian food prepared by Pakistani chefs. Chicken jalfrezi, lamb korma, naan, dal, vegetable pulav, the list goes on. More about them in the next post.

Building stakeholder participation and the challenges of being an outsider

This week began with a frenzy of meetings and trips to the counties. One of the key steps in building capacity is seeking stakeholder buy-in. The recipients have to buy in to the principles before we begin building capacity and strengthen the health system. Stakeholder participation is key!

In my efforts to strengthen the Liberian health system, I am committed to build capacity at both central ministry and the county health department level. I have already made the rounds at the ministry, having met with the key deputy ministers, assistant ministers, and senior management. I presented my strategy and won them over. I have also convinced non-ministry stakeholders - USAID, NGOs, and EU - to support and participate in my efforts. This week I am focusing on county heath departments. I just returned from a trip to Bong and Nimba counties where I met with the County Health Officers and their teams.

The two counties were polar opposites. While the county health team (CHT) at Bong was unresponsive, aloof, and nonchalant, the team at Nimba was active, participatory, and invested. A sea of change. Our project (RBHS) is well entrenched in to the Nimba county health system. See picture below. Our County Coordinator and the County Health Department Director (CHDD) share the same office space. That shows how well we work with the ministry at county level. Perhaps Bong could use the same level of involvement in order to become more invested in our efforts. It's on my to-do list.

Integration between the County Health Department (CHD) and our project (RBHS)

It is always challenging for an outsider to get local stakeholder buy-in, especially when you are someone like me. But I like the challenge. It allows me to prove myself and gain the trust of stakeholders in the process. I am sure I am not the only one who experiences this phenomenon. The new person is always tested, especially if s/he is an expat. It is part of the game, and I like a good game. The situation gets worse when the new guy is promoted within less than two months on the job. While it is frustrating to deal with such petty drama, it also makes me stronger and more invested in doing what I came here for.

I am going to visit the remaining county (Lofa) this week. I am traveling with my staff to a town called Voinjama, which is less than an hour away from Guinea. Too bad I cannot cross in to Guinea... I need a visa. I do not have enough time to get a Guinean visa before leaving on this trip. Next time!!

I ate at a Bangladeshi restaurant during my trip to Bong and Nimba counties. We stopped in a town called Gbarnga (pronounced - banga) to eat at this restaurant called Mama Zone's. The name struck me as strange, especially for a restaurant run by a Bangladeshi man, but I guess they are trying to blend in to the Liberian society. I came to know the restaurant exists in Gbarnga because there is a big Bangla UN military contingent nearby. Word on the street is that there are around 2000 Bangladeshi military personnel as part of the massive UN military presence in Liberia. You cannot just walk in to Mama Zone's and order Bangladeshi food, you have to order it an hour in advance. They prepare according to demand. The Liberian food, however, is readily available. We called ahead and had chicken curry. It was quite mediocre, even a disappointment.  As wonderful as it is to see non-Liberian food in the middle of the country, it is disappointing when the food is not good. Lesson learned! Next time I will stick to potato greens and fish.

More to come later this week...my trip to Lofa, other happenings at work, and more importantly, food!!