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.