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.