Ebola update

Two days ago we received an email from the CDC Chief - Tom Frieden stating that we have moved to EOC Level 1. This is the highest level of activation, reserved for the largest-scale responses, which often require substantial agency-wide effort.The Emergency Operations Center (EOC) moving to a Level 1 means that "all hands are on deck" for the Ebola response. Level 1 is the highest on a scale of 1-6 and it means that increased staff and resources will be devoted to the outbreak. It enables CDC to pull resources from across the organization to use in the response efforts. Since I cannot post the email here, I will post a link to the accompanying news article, which you can read here. 

In addition to the announcement about Level 1, Dr. Frieden's email also included a call for volunteers to help the CDC response in the region, particularly French speakers. I don't know how I feel about volunteering at the moment...it is something I have to talk to Michael about. On one hand, having worked and lived there, I know Liberia and its health system like the back of my hand; on the other hand I am not going to put my family at risk and add to their worry. Something to think about...

Regardless of volunteering, I will monitor the situation closely from my post in Dar es Salaam.

Ebola shows no signs of fading away in Liberia

The Ebola scare in Liberia and neighboring Sierra Leone and Guinea is getting worse every day. There are now two Americans that have been infected with the virus. One of the popular doctors in Monrovia - Dr. Brisbane - passed away over the weekend. Another popular doctor in Sierra Leone is currently infected. If you live in that part of the world it feels like perhaps this is the "big one".

Over the weekend I have come to know from my ex-staff in Liberia that Dr. Samuel Brisbane passed away from Ebola. Liberians are grief-stricken by the loss of the Chief Medical Officer of the most famous referral hospital in Liberia - JFK Hospital. I had the privilege of meeting Dr. Brisbane during one of the many meetings at the Ministry of Health and Social Welfare (MOHSW) when I worked in Liberia. I did not know him outside professional interactions, but he always brought a good spirit to the JFK hospital whenever I visited for work. And, most importantly, he was respected as an authority in medicine. I can only imagine the morale of JFK staff at the moment, after their beloved leader passed away. 

There are numerous mainstream media reports on Ebola in West Africa. However, I feel that most of them are not comprehensive. While I have known for a while - through my ex staff in Liberia - that the situation on the ground is not entirely reflective of what is being reported in the media, most of the my friends and family back in the US are not being told the complete story. Only recently are we hearing reports of communities refusing access to Médecins sans Frontières (MSF) in Sierra Leone and Guinea. Some of us have been hearing these reports from almost three months ago. This animosity towards MSF is important to notice because MSF is one of the few organizations that has consistently been at the forefront of the outbreak response. If MSF is denied entry into communities and cannot provide care, the crisis will undoubtedly get worse. My ex staff in Liberia tell a similar story of family members threatening clinic staff with physical violence and taking away their infected family members from the hospitals to care for them at home. The communities do not trust the medical care and believe that quarantine is a way of "controlling" the locals. In fact, the situation in Liberia has gotten so bad with families hiding their infected family members that President Ellen Johnson-Sirleaf had to issue a government order stating that hiding Ebola-infected members from medical care is a punishable offense. 

We are now hearing of a suspected Ebola death in Nigeria that may have come from Liberia. If Ebola has spread from Liberia to Nigeria, I am afraid it has spread to the countries in between - Côte d'Ivoire, Ghana, Benin, and Togo - because of porous borders. As of a few days ago, President Johnson-Sirleaf has restricted movements in and out of Liberia. The land borders are to remain closed but the Roberts International Airport remains open with possible testing for passengers who are entering and leaving the airport. Considering my past experience in Liberia, I do not put much stock in how or if this testing will be conducted. However, it is a important step in disease surveillance. 

So far all my ex staff are safe and sound, in spite of working in the infected areas. I pray for their safety and hope that the outbreak subsides. This is one event we need to closely monitor and take measures to contain the infection. As we used to say during our work meetings at the MOHSW - "God bless Liberia!". Even though I do not live or work there anymore, Liberia will always be in my heart and well wishes. Liberians always believe God will save Liberia and its people...this is one time that God may want to step in and give hope to the Liberians. 

Lone Star Forever!

Ebola in my beloved Liberia

The past few weeks have been very nerve-racking due the Ebola outbreak in Guinea that has now spread to Liberia. As many of you know, there is an outbreak of Ebola in Guinea at the moment that has reached crisis levels with over 60 deaths attributed to the disease. You can read more about the outbreak here and here.

Like most countries with porous borders, Ebola outbreak in Guinea means Liberia and Sierra Leone are next in line. Senegal has already shut its border with Guinea to prevent spread of Ebola. Reports have emerged about deaths in northern Liberia from Ebola, particularly in the Foya and Zorzor districts of Lofa County. I fondly remember the time I spent working in the Foya and Zorzor hospitals when I was working in Liberia. Lofa County was my favorite to visit because I could stay at the United Nations battalion stationed in Voinjama. The battalion was Pakistani and it had the best chicken curry and nan I had in West Africa.

Needless to say I was worried about my ex-team members who work in Lofa county. I called/ emailed them and they are all safe as of today. They are disappointed by the response from international community towards containing the disease. Being health care workers, they are worried about the fact that they still do not have adequate personal protective equipment. However, that does not stop them from providing health care for the needy. No matter where I've been in the world I always encounter health care workers who spring in to action regardless of their safety. It is what makes the clinicians a unique class of people. I am proud to be one of them.

I would like to share one of my favorite pictures from Liberia, which was taken in a clinic in Lofa County...which is now the seat of Ebola scare. I am showing one of the nurses how to enter antenatal care data in to the ledger. I miss my staff...

This Ebola scare has brought back so many fond memories of Liberia and concern towards my staff. I will be closely monitoring the developments and pray that the disease is contained and the Guineans/ Liberians/ Sierra Leoneans do not suffer any further.

The best reward

Allow me to paraphrase an old Taoist saying: " The best leaders are those the people hardly know exist. The mark of a successful leader is when the team says WE DID IT!"

I have always believed a leader is only as strong as his/ her team. My work has consistently given the opportunity to build the capacity of my team and others involved in my work. The effort you put in to building a team's capacity is directly proportional to the quality output. Now, what is all this talk about leadership, you may ask? Strengthening health systems has a lot to do with leadership. Building the capacity of workforce and the system requires leadership qualities. That is why I sought a doctorate in public health leadership after my medical degree. I am firm believer that leadership is essential to build and strengthen health systems.

So, what is the exact relationship between leadership and health systems strengthening (HSS)? Allow me to give an example. HSS requires a commitment and buy-in from various stake holders, government and non-government players included. Anyone heard of "From silos to systems"? Strong leadership qualities are an absolute necessity in securing these commitments and buy-in. A successful leader will engage all the players and bring them together to build a strong health system. That is what I have always done in my line of work...engage, secure commitments, and obtain buy-in. It is the first and crucial step towards building/ strengthening a health system.

My work in Liberia is a testament to successful leadership. I can proudly say I was responsible for conceptualizing, operationalizing, and initiating the first and only comprehensive HSS/ capacity building framework for a post-conflict country. It would not be possible without the commitment and support from various stakeholders and my staff. Starting from the Liberian Ministry of Health to international donors like USAID and various NGOs, everyone played a role. I am proud to have created and implemented a framework that facilitated the stakeholders to come together and rebuild Liberia.

Besides stakeholder buy-in, a successful leader is also appreciated by his/ her team. It has been almost six months since I left Liberia and I continue to receive messages from my staff and colleagues about the impact I made in their career. The best message is one I received from an ex-staffer which read "Thank you for all that you have done. WE are now able to work towards rebuilding and strengthening our health system". I capitalized the word "we" to emphasize the mark of a successful leader. The message brought a tear to my eye. I am glad the ex-staffer said "we". I never want things to fall apart after I leave, and I am glad my ex-team is following up and making things happen after my departure. I take pride in them and I am blessed to have had the opportunity to build their capacity, which enables them to continue with the work I started.

A latest message from an ex-colleague in Liberia made me think about leadership today. She wrote "good to know that you are working in Kenya. I know you will help people in Kenya like you helped my career". Am I a successful leader? I may not fit the stereotype of a traditional leader, but I possess some leadership qualities. I will, however, say with certainty that I will continue to build the capacity of people and health systems in order to prove myself as a successful leader in my line of work.

While I appreciate every opportunity I have been given, I am particularly appreciative of the fact that my teams always say "WE DID IT!". The sense of camaraderie among the team members and the stakeholder buy-in will continue to be the best reward of my career.

Onwards and upwards!

New adventures

Wow! That was a long hiatus. My last post was in October 2012. I am back to blogging after hiding for six months. Apologies for anyone who was expecting an update.

There is plenty to report since October '12, but I will keep it brief. I had a fantastic time speaking at the American Public Health Association 140th annual conference in San Francisco at the end of October. I organized a panel discussion on rebuilding health care services in Liberia. I spoke along with the Deputy Health Minister from Liberia. Click on the panel discussion if you are interested in learning more about the topic.

I left Liberia in December 2012 and traveled across India, Thailand, Costa Rica, and the US. It was great to get away and travel with Michael. We haven't done that in a while and it made me realize - yet again - why he is the perfect man for me. Costa Rica holds a special place in my heart as the only country I visited where I was able to fully relax and not worry about a thing. Guess I needed the break after all!

Of course, being the work-obsessed person that I am, it is difficult to stay unemployed for long. Opportunity came knocking in the form of a great job opportunity with PSI. I accepted a position to lead a project aimed to inform policy and decision making for improved access to antimalarials and diagnostics across 8 African and 2 Asian countries. I am based in Nairobi, Kenya with frequent travel to Benin, Nigeria, Uganda, Democratic Republic of Congo, Zambia, Tanzania, Madagascar, Cambodia, and Myanmar. I moved to Nairobi a week ago and I am loving this city so far.

That's it folks! Now you know why I haven't been actively posting. I will resume blogging now that I am settled in Nairobi. 

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?

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".

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!!

Lowise's Bar & Restaurant and the glory of palm butter

I love everything about food. I like knowing where it comes from, how it is prepared, what ingredients go in a particular dish, the smells, the taste, the experience, everything. I should be morbidly obese considering my love for food, but I've managed to stay in shape because I practice mindful bingeing. It is a delicate balance of being cognizant of what I eat and eating copious amounts of food frequently.

I could be like most expats here and bring my own lunch (sandwiches anyone?), but I like to experience local flavor and explore. Most of my local staff eat at a place called Lowise's Restaurant (yes, that is how it is spelled). It is pronounced Louise. I have been eating at Lowise's for almost a month with no problems. I usually have someone fetch it for me because I am running in between meetings or buried in papers, but once in a while I walk over and eat at Lowise's. It is only a block away from my office. The restaurant serves only one special every day. They have the standard dish - dry fish and rice - and one daily special. I can never remember the schedule of daily specials, but I particularly like some of the specials. Cabbage with fish, and potato greens with fish are my favorite. I specify fish because if you don't, you will end up with a melange of meat in your dish. I have identified pork knuckles, beef rib tips, chicken feet, and fish heads...all in one bowl. As adventurous as I am, I prefer to eat one kind of meat at a time. I am not a big fan of beef, I prefer my pork in the form of bacon and pork belly, and I like my chicken feet in black bean sauce (dim sum). So, I stick to ordering my dishes with fish alone. Liberians tend to use almost every part of an animal, so expect to see fish heads, fins, tail, pretty much everything in a dish. Here is a picture of the daily standard dish - dry fish and rice. They say it is dry fish, but it is a whole fish, usually a snapper, deep fried and served with jollof rice. It is quite delicious, if I may say. Look at the teeth on that fish. One of my friends said it looks angry. Of course it is angry, it's been fried to death!

Dry fish and rice

Let's talk about Lowise's Bar & Restaurant. It is quite dingy, inside and out, but the food is good. Service varies by day. I have seen the same lady serve us patrons. Some days she is cheerful and makes small talk, some days she is just plain grumpy and mean. She looks young, talks on the phone a lot when she is not serving, and on some days her accent is difficult to understand. She adds charm to an otherwise dull restaurant. The music is always loud at Lowise's, almost to the point where you have to scream your order. I have suggested a few times they may want to tone it down, but they don't listen. Now I just scream my order. One of these days I hope to catch a glimpse of Lowise. All I know is that she is cooking in the back, she never makes an appearance in the restaurant. As the name suggests, there is a bar inside. It is quite small and they carry beer, water, soft drinks, and energy drinks. I don't drink at work, so I haven't tried any beer. Below is a picture of Lowise's restaurant. I have to give credit to Michael for taking this picture.

Lowise's  Bar & Restaurant

Today's daily special is palm butter. I have heard a lot about this dish since arriving in Liberia. Locals claim that, even though you can find this dish in other African countries, nobody makes it like the Liberians. Beautiful red palm fruits are mashed to create an oily sauce and meat is added. The mashing is done with hands, not a machine. Needless to say, it is a laborious process. As you may know, palm oil is very high in cholesterol. It is not good for your heart, but like most stuff that is not good for you, it is very tasty. The dish is called palm butter, because it practically is meat in a sauce that looks like melted butter. Very unhealthy but oh so tasty! I avoided it since arriving in Liberia because I am afraid of the fat content. I finally caved in and ordered it. I saw the table next to me order it and it looked and smelled delicious. My verdict: it is glorious, but too heavy for my arteries. I may have it once a year. I want to live long enough to visit various countries.

Here is a picture of the culprit. I scooped out SEVEN tablespoons of palm oil before taking this picture, and it still looks greasy. That should tell you how unhealthy it is. As mentioned earlier, there is some mystery meat in it because I forgot to mention "fish only". I was not able to figure out the meat, for all I know it is a part of a cow or Baboon (which is not uncommon here). Did I eat it all, including the mystery meat? You betcha!

Palm butter with mystery meat

In other news, Michael and I went to Miami Beach over the weekend. As I mentioned to my friend who lives near the real Miami Beach, the one in Liberia differs from the one in Florida in two aspects: amount of silicone and number of people. Usually it is just Michael and I on the beach, except for some days when someone brings their dogs to the beach (see picture below). There was a football (soccer for you Americans) match happening on the beach when we went, just a few guys kicking the ball around. We stayed for a while until the sun became intense and came back home.

Dog days at the beach

There is a bar on Miami Beach, which plays dance music at a deafening level all the time. As we were leaving the beach, the bar owner came over and talked to us. His name is Sunshine. I am not kidding. We didn't stay at the bar, but Sunshine invited us to come back again in the evening. One of these days we will take him up on the invitation.

A lot is happening on the work front. I got promoted as the Director of Capacity Building and Health Systems Strengthening in less than 2 months of being here. With promotion comes more tasks, drama, and the responsibility to supervise more staff. I realize it is part of the equation and I am thoroughly enjoying all of it. I will write more about work in the next post. Till then, cheers to palm butter!

What does it mean to build capacity and strengthen a health system??

The one question I have been trying to get answered, since I've been here. I may finally have an answer by the end of this month. I have to warn my friends reading this post: it is going to be all about work, no personal or fun stuff here.

Plato once said "the beginning is the most important part". I always believe the beginning of a project sets a tone for what's to come. One of the preliminary and major tasks of building capacity in health systems is to "define" what building capacity means for the recipient. Some call it developing a "vision". Whatever terminology you may prefer, the common understanding is that the recipient should be able to "define/ envision" what building capacity means for them.

My priority task, since I've arrived in Monrovia, has been to help/ guide/ persuade the Ministry of Health come up with an idea of what building capacity means for them. Why is this important? I'll give you another quote (I am full of these quotes today). To paraphrase what H. James Harrington wrote in Business Process Improvement:

"In order to strengthen/ change a system you have to control it;
in order to control a system you have to understand it;
in order to understand a system you have to measure it"

In my quest to strengthen/ change the health system in Liberia, I realize the need to measure it. Measurement requires definition. That is why I need the ministry to define building capacity and strengthening the health system. I could do it myself (I am thoroughly capable and competent), but I am not here to tell people what to do. I am not a dictator (although, in my spare time, I pretend to be one wearing a ridiculous crown). I am here to help, enable, and advise. So I proposed a few definitions and helped facilitate a discussion. We are making progress in coming up with a common vision.

Few days ago I delivered a talk to the senior leadership at the Ministry. It was well received, they were engaged in the discussion, and the best outcome - they agreed to finalize the vision for capacity building very soon. I am happy about this development. Now that I am gathering stakeholder participation and support - a vital component of strengthening a system - I am focusing on stakeholders at both central and county/ district level. The central ministry has heard (and got on board) with my strategy to build their capacity and strengthen the system, now it is the county and district health departments to get on board. In order to accomplish this buy-in, I will be traveling to the counties - Lofa, Nimba, and Bong - next week. I will present my strategy, introduce the instruments, and seek feedback.

The framework I am following to strengthen Liberian health system and build capacity is the WHO framework. It describes six building blocks that form the basis of a health system. Building Block 6 - Leadership and Governance - is the one that interests me the most. I strongly believe leadership capacity is the one that guides the other five building blocks. Allow me to share a diagram from the WHO framework

Six building blocks of a health system

As you can see, all building blocks work in unison towards creating/ strengthening a health system, but leadership is the one that guides other building blocks.

I believe we need strong leadership and a capacity to govern fairly in order to have a viable health system. Leadership is something that is lacking in the health system here. There are a few people at the central ministry who understand the importance of leadership and see the big picture, like Deputy Health Minister Yah Zolia, but leadership at county and district level is severely lacking. One of my objectives in building capacity for the ministry is to build their leadership capacity. I will be conducting an assessment of current leadership in the ministry - both at the central and county level - to identify issues that plague leadership. This assessment will help us develop a strategy to build leadership capacity.

Of course leadership is only one of the six building blocks of a health system. There are five other blocks for me to focus...and they will all receive due attention. I am using resources from WHO and CDC to create assessment tools for the Liberian ministry. These tools have been adapted and tested in other countries. I have first hand experience with these tools, having adapted and implemented them to health systems in Israel and India. I do not have to tell you that post-conflict systems are a completely different ball game. There are developed systems (US and most of Europe), emerging systems (India), and then there are post-conflict systems. There are not many frameworks/ instruments that have been developed specifically for post-conflict health systems, and that puts the burden on people like me to adapt existing frameworks to post-conflict settings. I like the burden because I like a good challenge. In the beginning I thought it feels like going back to the drawing board, but I have come to realize it is not even that. It is more like understanding that I need a board and pencils to draw, then embarking on a journey to procure the board and pencils before I begin drawing on a board. That's the level of  system in a post-conflict setting. Needless to say, it is challenging but extremely rewarding.

I have a lot of work ahead. We will start assessing baseline capacity next month and that will lead us to developing a capacity building and health system strengthening strategy. Analyzing the data and developing a strategy will take 2-3 months. We intend to start implementing our activities in June. I see a poetic sense of beginning because June is also the rainy season. To me, rain has always symbolized the beginning of a new adventure. It will be perfect for our adventure to begin in June.

I promise the next post will be not as dry as this one. I will add more personal and fun stuff, perhaps some pictures, for my friends.