Dear Friends,
I promised to tell you about the hospital. Let's start with measles.
About a month before I came, there was a measles outbreak. By the time I showed up in the pediatrics ward, babies were presenting with the sequelae of measles, namely pneumonia and skin ulcers. If a child survives measles infection, she has severe malnutrition because her gut sheds so much of its outer layer that it can't absorb nutrients from food. The malnutrition leads to poor immunity and infection. Several of these babies had black teeth, the worst tooth rot I have ever seen. (I thought I had seen some pretty rotten teeth among the homeless of Worcester.) It's a stark contrast to the teeth of most adults here; for some reason, most adults here have very clean, even, square white teeth. I wonder if the chlorine in the water acts like fluoride. In any case, skin breakdown occurs and subsequent infections. One little baby, just a few months old, had open ulcers on his groin and laid on his back, breastfeeding and crying from the pain, for days.
Measles outbreaks do occasionally occur at home, but generally they occur in patients who have traveled and are not vaccinated. The Liberian government has recently done measles and polio vaccination and deworming campaigns for child health. I happened to catch a ride one day with some of the health workers who came out to administer the campaigns from Monrovia. They have a difficult task: they ride through the bush on dirt roads to find people who live in small clusters, hardly even villages, in the middle of the bush, to vaccinate them. I sympathize with them. In my small experience going out with our accompaniers to try to find, or “trace,” lost patients, I was often at a loss for what to do. I would arrive at a village in the late morning, only to learn that the person we were looking for had gone “to the farm,” which was an unidentified distance away, likely through narrow trails in the woods. I gave up easily. But these vaccination teams are supposed to go and find every child, in a place where there are no records of how many children there are, no birth registries, no compulsory schooling. Furthermore, many vaccines require several administrations over months or years. It's hard to keep track of the vaccine schedule in the US, where kids are carted to the doctor's office by their parents. Going out to locate them in the forest to vaccinate them, and to ask their parents to keep their vaccination records, sounds like a logistical nightmare. With these challenges, it's not surprising that there are outbreaks of measles. Although, unfortunately, I hear that the vaccination teams also fudge their numbers to make it look like they've reached more children than they have.
Compulsory, free education, linked to vaccination, would probably be the best prevention for measles (and all the other vaccine preventable diseases), but I wonder if anyone in the health sector is advocating for it. In general, the notion of compulsory free education is a wild idea to most Liberians I have spoken to. One 26-year-old asked me, “Does anyone in the US graduate high school by the age of 18?” I thought he was joking. But he had graduated at the age of 24, which is not abnormal. I have met 18- and 20- and 22-year-olds who are in seventh grade. They have to pay their own way through school, so they stop and start as money is available. The poor education reveals itself in small, surprising ways. I've been teaching sewing classes to the women's group, and the difficulty they had holding the scissors reminded me that I learned even that simple skill in preschool.
Sorry for the education tangent. Returning to the hospital, malaria: Malaria is by far the most common diagnosis in the hospital. It's so common that patients come in telling you that they have malaria, and it's like pulling teeth to get them to actually state their symptoms so the clinician can decide for him or herself the patient's diagnosis. Malaria is potentially life threatening in both children and adults. But the pediatric cases I've seen stand out as particularly hard. I watched one 5-year-old die from malaria, her lungs full of fluid. Her breaths slowed to two per minute as the staff tried to find IV access and failed. Her parents wailed and ran down the hall when she died. I met a 3-year-old with cerebral malaria. He had the peculiar history of getting a generalized muscle rigidity every time he had a fever. I saw him over several days, with stiff legs and pointed toes, like a frozen ballerina. His head was turned to the side, and his arms were up and flexed in a fencer's pose, a primitive reflex indicating brain involvement. He whimpered and spoke to his mother through tense jaw muscles. He was treated for tetanus and malaria. He did not respond to the tetanus anti-toxin, but did slowly to the malaria treatment.
Typhoid: Typhoid has a vaccine, but it can be overwhelmed by “large inoculum,” a.k.a. eating a large amount of Salmonella typhi in one go. The available vaccines also don't protect against Salmonella paratyphi, the other causative agent of typhoid. So the vaccine doesn't work that great. It is not routinely administered, and there are trials to develop better vaccine so that ideally, it could be routine where needed. (I had to check my own vaccination record to see if I had been vaccinated. Yes, two years ago, but only because I went to Brazil.) Typhoid is relatively common here, which is unfortunate because it is spread only through poor sanitation. There is nothing unique about a tropical environment that facilitates it. It is only helped by a lack of running water and handwashing, pit latrines, and cockroaches to spread the germ between latrines and the breakfast plate. One patient I saw with a possible typhoid had a stomachache and a taut belly, tight as a drum. Tapping on it, it sounded clearly full of air, so much so that it was pushing up toward his lungs, making it difficult for him to breathe. If his air-filled stomach was indeed caused by typhoid, then he was at risk for perforating his bowel. In order to reduce his perforation risk, he was given an enema. I never found out what happened to him, though, because the next day on rounds, he was gone. He had left the hospital overnight, against medical advice.
HIV: Philip sometimes points people out to me around town who he has seen test positive in clinic but do not take medication because they have what he calls internal stigma. At home, most patients hospitalized because of HIV fall into this category. For one reason or another, social, psychological, economic, they know their diagnosis, but do not treat. Here, however, most of the hospitalize HIV patients are newly diagnosed. One woman came in with an angry series of painful sores on the left side of her face, swelling her eye shut. Such a severe case of herpes zoster is unusual in people with normal immune systems, so an HIV test was ordered for her. She was positive. A 22-year-old man who came in severely wasted, all skin and bones, who laid in bed with glazed over eyes, conscious, but not answering questions. His altered mental status was due to...meningitis? HIV encephalopathy? Without the tools to do a lumbar puncture, we could not definitively diagnose him, so, he was treated for meningitis, in case of concurrent infection. It's too bad, to have to use precious drugs to make diagnoses via empiric treatment, in a place that has a limited supply of everything to begin with.
Obstetrics and anesthesia: The obstetrics that I have seen here has only been surgical, that is, patients who have had a complication that necessitates surgery. The vaginal deliveries are, for the most part, handled by midwives. (In fact, when I went to the OB ward and asked for the doctor, the midwife was offended that I didn't take her qualifications seriously. I had to apologize and explain that I wasn't used to having midwives available.) So unfortunately, the obstetric cases I have seen have been dramatic. The most recent was a woman who came in, complaining that her baby had stopped moving. She was full term, but on exam the baby was high in her belly and close to the skin. On ultrasound, her uterus was empty. Her vitals were stable, so we assumed that she had had the rare diagnosis of an abdominal pregnancy, i.e. a fetus that grew in the abdominal cavity and not in the uterus. In the OT, we were proven wrong: the woman's uterus had actually ruptured, emptying the fetus into her belly. She received a hysterectomy, after the surgeon confirmed that she had 6 children already. It was remarkable that her vitals had been stable for so many long hours. (Emergency surgeries don't happen so “stat” here.)
If the drama of watching the surgeon perform this life-saving surgery was not enough, the anesthesia started wearing off in the middle of the procedure. Mid-surgery, the patient was moaning and moving her hands and feet. Her belly was open and her uterus was being taken out. At one point, she reached forward with her right hand and actually grabbed at the surgeon's gown. He looked down at her hand, mildly surprised, and since the nurse anesthetist was busy tying her other hand down and finding more anesthesia, I slipped in and held her hand out of the sterile field. I stroked it for reassurance at times, and literally arm wrestled with it at others. I had to focus to prevent my own lightheadedness. The poor anesthesia was distressing me. The patient made it through the surgery, and the next day, she thanked the doctor for saving her life. I wonder what she remembered.
Disease here is not all social and infectious disease, and care is not only defined by the paucity of resources. Despite the stories I have chosen to tell, a lot of the medicine here is the same as it is at home. Counseling and kindness are practiced in both places. For example, after rounds last week, our new clinical director, a young Ugandan man named Dr. Kalisa, went to see the mother of a hospitalized, malnourished child to explain what good nutrition entails and how to provide it. Another day, he asked the nurses to wheel a severely depressed patient outside so she could see the sun and perhaps feel some will to live. These small touches, which aren't prescribed by any protocol, are thankfully practiced by good clinicians everywhere.
I truly admire the breadth and depth of knowledge that the African doctors have. The Ugandans I have worked with transition from quiet patient counseling to pediatric ICU care to fast-paced surgery effortlessly, and on top of that, they are have been so good-natured and unflappable. Although some of the doctors at Martha Tubman are Liberian, none have received their training in-country. They have all trained in Uganda and Nigeria, both post-British-colonized countries with good and intact education systems. Similarly, there are no Liberian medical students here, only myself and Clare, a British medical student here with Merlin. Only four to twenty medical students graduate from the University of Liberia each year.
My mind is not playing tricks on me: people do die here more frequently than at home. I have heard about more funerals in the last month than I have in the last ten years of my life. The scrub nurse's mother died, our outpatient clinician Othello had a death in the family, one of our staff members, James, had an uncle pass a few weeks ago. And I have heard the explanation, “She went to Ivory Coast for a funeral,” from the accompaniers who are tracing patients more than several times. In this setting, then, it doesn't surprise me that the routine safety pause spoken by the nurse before surgery is a prayer to God. Sometimes the prayer is made for the patient, and sometimes it is made for the doctor. At home, before the first incision, the nurse pauses only to recite the patient's name, date of birth, and the procedure to be performed.
Thanks for reading. Next time, I hope my missive will be a little lighter. I'll tell you about some of the fiction I've been reading.
Good night and good luck,
Roona
Wednesday, May 26, 2010
Thursday, April 29, 2010
29 April 2010
Dear Friends,
My friends Raj, Justin, and Ana left a few days ago for the US via Monrovia and then Europe (if the Icelandic volcano ash covering all of Europe cleared up). I was sad but am looking forward to hanging out with people in Zwedru over the next month. The people here, both the ex-pats and the Liberians, have been so nice to us so quickly. I'm lucky to have met so many nice people in my life. A few weekends ago, Raj said to me, Wouldn't it be great, if in a few years time, when people ask how we achieved our goals, we could say, "We just hung out a lot"? He made me laugh, but he reminded me that I do like to hang out.
Last week, a group of us went to visit the farm that Philip's support group for people living with HIV/AIDS (PLWHAs) has started. It was a ten minute drive out of town, on the dirt road to Monrovia. We got out of the car and met some of his family, then walked five minutes through the forest until we reached a clear cut area. The farm is very new; there are some parts that are still being cleared. They are slashing and burning in order to make farm land. I've heard that that's not a sustainable way to farm because so many of the nutrients are burnt away, but Philip said the land is actually quite rich. In general, the farming here is done entirely by hand, the clearing, the planting, the weeding, the fertilizing, the harvesting, and it's pretty much subsistence, as evidenced by how quickly food runs out in the market and how hard it is to get anyone to sell you their fruit. (A British NGO worker I met from Grand Kru, a place so remote that it makes Zwedru look like a bustling metropolis, told me that the concept of market—even barter—is so fragile there that it's hard to get food sometimes. People just don't want to give you what they have. This disinterest in trade boggled my Wal-martized mind, of course.)
A few days later, Philip asked me about farming in the US, and I described what little I've learned of industrial farming from driving by big farms: huge machines that dig and plant and water and harvest; farmland in California, where desert and saline soil is transformed into arable land through irrigation and piping water hundreds of miles from the mountains; the powerful agriculture lobby and how our government subsidizes agriculture and reduces the economic risk involved in farming. He liked the idea of a company, which is what he said his dream was for the PLWHA farm. He was curious about livestock, so I told him what (again, little) I know about factory farms and how we give our animals hormone injections and prophylactic antibiotics and produce huge amounts of food, surplus even. As we spoke, Zwedru's only tractor happened to drive by us. Philip said it was owned by that one rubber farmer that my neighbor told me about a few weeks ago, and only used to haul large loads around town, not actually for farming because, as far as he knew, no one had the tilling attachments that you drag behind it. Sounded a lot like the hospital equipment situation. I have a couple of friends who know more about farming than I. I wonder if they have any suggestions for online (or other) resources for Philip and his friends. They are hungry for knowledge about farming.
In some ways, I imagine Zwedru is like many other places in the world: there is a lack of resources and knowledge and education and functioning systems to give people opportunities to grow and develop. However, there is also a lack of resources here that is uniquely due to the recent history of conflict. In talking to people around town-—the drivers and security guards and hospital staff and Tiyatien staff and members-—it seems like everyone lost someone in the war. I've talked to several adults in their twenties and thirties, including some of the Tiyatien staff, who lost both of their parents in the war, when they were teenagers or younger even. (Locals darkly joke about the NGO Save the Children: they call it “Save the Children, Kill the Parents.”) In addition to the overwhelming emotional devastation, it's staggering to think about the loss of knowledge and tradition that comes with that loss of a generation. There are definitely no old institutions, like schools or universities here to pass knowledge and opportunity and stability. It's hard not to compare it to Erfurt, Germany, the small town that I spent a day in a month ago, on my way here. My friend's family showed me the town's sights, which included one of the oldest universities in Germany; it had been functioning for 600 years or so! There are not even many old people here, and by old, I mean older than 50. While you do find the odd outlier here and there (Kerry's oldest Liberian patient was 98), it's pretty unusual to see white hair on people's heads. Life expectancy here is 45.7 years, vs. 82.6 years in Japan vs. 78.2 years in the US. A lot of that 45.7 is due to war casualties, but a lot is due to poor healthcare and infrastructure. I entered some data in my first week here on the names and ages of the HIV patients who have died since August 2009, and they, too, contribute to the low numbers: they were in their 20s, 30s, and 40s, with a few children under 5.
Ana said a few days ago that prior to 1994, no one lived in Zwedru. People fled in the late 1980s and early 1990s, to Cote d'Ivoire, Guinea, and some even farther afield to Nigeria, Congo, South Africa. Some, like Raj's family, went to Sierra Leone or the US. The largest concentrations of Liberians in the US are in Washington DC, Maryland, Minnesota, and Massachusetts, many actually in Worcester, where I've been living for the past four years. In some part, the people who are repatriating are reinventing their society.
When we were in Monrovia, Raj and I ran into a friend from public health school who just started a job to strengthen the health sector. He has worked in Afghanistan, and he said that he had a soft spot in his heart for post-conflict areas because of the potential for change. After a few weeks here, I can see what he means. There are a lot of Liberians like Raj, who fled as children or young adults, who have come home to help rebuild. In the airport on the way over, we met and hung out with a guy named Kimmie Weeks, who has started a group called Youth Action International, which works to disarm children and improve opportunities for them. He is in his late twenties and got his education in private schools in the US. He splits his time between the US, Uganda, here, and Sierra Leone, all places with ex-child combatants. And in Monrovia, we met a minister at the Ministry of Health who told us that he returned from a comfortable life in Minnesota because Ellen Sirleaf-Johnson asked him to return and contribute when she was running for president. He said, she won, how could I not return? There is a lot of love in these repatriates for their work.
Okay, signing off from my perch in Zwedru. Next time, I'll tell you about the PLWHA support group and the Zwedru Women United for Change meetings that I went to last weekend. The latest on the fruit front, for those interested in the amount of fiber my GI tract is getting, is that Kerry gave me a whole pineapple and papaya yesterday. I felt like a rich woman. They were sun-ripened (unlike the tropical fruit we get at home) and so so good.
Good night,
Roona :)
My friends Raj, Justin, and Ana left a few days ago for the US via Monrovia and then Europe (if the Icelandic volcano ash covering all of Europe cleared up). I was sad but am looking forward to hanging out with people in Zwedru over the next month. The people here, both the ex-pats and the Liberians, have been so nice to us so quickly. I'm lucky to have met so many nice people in my life. A few weekends ago, Raj said to me, Wouldn't it be great, if in a few years time, when people ask how we achieved our goals, we could say, "We just hung out a lot"? He made me laugh, but he reminded me that I do like to hang out.
Last week, a group of us went to visit the farm that Philip's support group for people living with HIV/AIDS (PLWHAs) has started. It was a ten minute drive out of town, on the dirt road to Monrovia. We got out of the car and met some of his family, then walked five minutes through the forest until we reached a clear cut area. The farm is very new; there are some parts that are still being cleared. They are slashing and burning in order to make farm land. I've heard that that's not a sustainable way to farm because so many of the nutrients are burnt away, but Philip said the land is actually quite rich. In general, the farming here is done entirely by hand, the clearing, the planting, the weeding, the fertilizing, the harvesting, and it's pretty much subsistence, as evidenced by how quickly food runs out in the market and how hard it is to get anyone to sell you their fruit. (A British NGO worker I met from Grand Kru, a place so remote that it makes Zwedru look like a bustling metropolis, told me that the concept of market—even barter—is so fragile there that it's hard to get food sometimes. People just don't want to give you what they have. This disinterest in trade boggled my Wal-martized mind, of course.)
A few days later, Philip asked me about farming in the US, and I described what little I've learned of industrial farming from driving by big farms: huge machines that dig and plant and water and harvest; farmland in California, where desert and saline soil is transformed into arable land through irrigation and piping water hundreds of miles from the mountains; the powerful agriculture lobby and how our government subsidizes agriculture and reduces the economic risk involved in farming. He liked the idea of a company, which is what he said his dream was for the PLWHA farm. He was curious about livestock, so I told him what (again, little) I know about factory farms and how we give our animals hormone injections and prophylactic antibiotics and produce huge amounts of food, surplus even. As we spoke, Zwedru's only tractor happened to drive by us. Philip said it was owned by that one rubber farmer that my neighbor told me about a few weeks ago, and only used to haul large loads around town, not actually for farming because, as far as he knew, no one had the tilling attachments that you drag behind it. Sounded a lot like the hospital equipment situation. I have a couple of friends who know more about farming than I. I wonder if they have any suggestions for online (or other) resources for Philip and his friends. They are hungry for knowledge about farming.
In some ways, I imagine Zwedru is like many other places in the world: there is a lack of resources and knowledge and education and functioning systems to give people opportunities to grow and develop. However, there is also a lack of resources here that is uniquely due to the recent history of conflict. In talking to people around town-—the drivers and security guards and hospital staff and Tiyatien staff and members-—it seems like everyone lost someone in the war. I've talked to several adults in their twenties and thirties, including some of the Tiyatien staff, who lost both of their parents in the war, when they were teenagers or younger even. (Locals darkly joke about the NGO Save the Children: they call it “Save the Children, Kill the Parents.”) In addition to the overwhelming emotional devastation, it's staggering to think about the loss of knowledge and tradition that comes with that loss of a generation. There are definitely no old institutions, like schools or universities here to pass knowledge and opportunity and stability. It's hard not to compare it to Erfurt, Germany, the small town that I spent a day in a month ago, on my way here. My friend's family showed me the town's sights, which included one of the oldest universities in Germany; it had been functioning for 600 years or so! There are not even many old people here, and by old, I mean older than 50. While you do find the odd outlier here and there (Kerry's oldest Liberian patient was 98), it's pretty unusual to see white hair on people's heads. Life expectancy here is 45.7 years, vs. 82.6 years in Japan vs. 78.2 years in the US. A lot of that 45.7 is due to war casualties, but a lot is due to poor healthcare and infrastructure. I entered some data in my first week here on the names and ages of the HIV patients who have died since August 2009, and they, too, contribute to the low numbers: they were in their 20s, 30s, and 40s, with a few children under 5.
Ana said a few days ago that prior to 1994, no one lived in Zwedru. People fled in the late 1980s and early 1990s, to Cote d'Ivoire, Guinea, and some even farther afield to Nigeria, Congo, South Africa. Some, like Raj's family, went to Sierra Leone or the US. The largest concentrations of Liberians in the US are in Washington DC, Maryland, Minnesota, and Massachusetts, many actually in Worcester, where I've been living for the past four years. In some part, the people who are repatriating are reinventing their society.
When we were in Monrovia, Raj and I ran into a friend from public health school who just started a job to strengthen the health sector. He has worked in Afghanistan, and he said that he had a soft spot in his heart for post-conflict areas because of the potential for change. After a few weeks here, I can see what he means. There are a lot of Liberians like Raj, who fled as children or young adults, who have come home to help rebuild. In the airport on the way over, we met and hung out with a guy named Kimmie Weeks, who has started a group called Youth Action International, which works to disarm children and improve opportunities for them. He is in his late twenties and got his education in private schools in the US. He splits his time between the US, Uganda, here, and Sierra Leone, all places with ex-child combatants. And in Monrovia, we met a minister at the Ministry of Health who told us that he returned from a comfortable life in Minnesota because Ellen Sirleaf-Johnson asked him to return and contribute when she was running for president. He said, she won, how could I not return? There is a lot of love in these repatriates for their work.
Okay, signing off from my perch in Zwedru. Next time, I'll tell you about the PLWHA support group and the Zwedru Women United for Change meetings that I went to last weekend. The latest on the fruit front, for those interested in the amount of fiber my GI tract is getting, is that Kerry gave me a whole pineapple and papaya yesterday. I felt like a rich woman. They were sun-ripened (unlike the tropical fruit we get at home) and so so good.
Good night,
Roona :)
Friday, April 23, 2010
24 April 2010
Friends,
I'm sorry I've taken so long to write again. In the last few weeks, I've learned that living at the equator is physically exhausting, and I'm often too tired at the end of the day to write. The metabolic demand is higher, the nutritional quality of the food poorer, the economic availability of food crappier. It's hard even to keep up with my fluid balance, since I sweat so much everyday and getting clean water is a mild rigamarole. And I am a person of relative means. It is remarkable that people continue to exist here under conditions of poverty.
Which is not to say I haven't had a good couple of weeks. My first full week here was about adjusting physically to a new place and lifestyle (and temperature). I learned how the cell phones work (pre-paid cards, pretty good coverage, shitty battery life in my case); how to hail a motorcycle (“You riding?”); and that the best thing to eat is beans in bread from the lady who sells them outside the hospital and homemade guacamole.
My second full week has been about starting to get to know the people in the organization. I've met Philip, a patient in the HIV accompanier program who was resurrected from near death, social isolation, and suicidality from AIDS, when given HIV medicines, and is now Tiyatien's livelihoods officer. He is employed by the organization to counsel other patients on how to improve their social conditions and means. He is a visionary: with his new lease on life, he started a support group for people living with HIV/AIDS and a farm for them to work on because he believes that they must have a way to support themselves. I've met Agatha, a tall, part-Malian woman who is starting a center for local women where they can come and meet and learn the skills they want to learn. She has the land picked out already. And I've met Alphonso, who works nights as a nurse aide in the hospital and days running the accompanier program for Tiyatien. He supports eight family members, yet has an incredibly sweet and optimistic disposition. I'm not sure I would be so optimistic myself were I working under such demands. I've been interviewing some of these people for TH's website, and hopefully I'll be able to get those interviews online, whether in audio or transcribed format, soon. They'll give you a taste of Liberian English, which at first I had a hard time understanding, but now seem to have an ear for, at least some of the time.
It's been an eventful couple of weeks, too. Two Mondays ago, soon after I last wrote to you, the entire non-physician hospital staff went on strike. The physician assistants, nurses, nurse aides, pharmacists, cooks, security guards, housekeepers, everyone. So the doctors, Kerry and four others, went to the hospital, discharged the patients who could be discharged, and ran the rest of the show themselves, to preserve patient care. From placing IVs, to finding and dispensing medications, to taking vitals, and nearly to cleaning up vomit in the hallway. Not to say that they, and we, didn't sympathize with and support the strike. We did entirely. One of the docs sometimes works for months without receiving pay because he's on government payroll, and he served as a negotiator for the striking staff. An unreliable paycheck is one of the main issues underlying the state of the healthcare system here, and the strike helped get the government in Monrovia to pay (some) attention.
Hospital strikes here are unusual. Raj says he's never seen one in the 4 years he's been coming to Zwedru, although they came close to striking a few years ago. Their demands were pretty straightforward: they wanted year-long contracts and to be paid and paid on time. Currently, they work without a contract, which means they have no job security and no proof of the terms of their employment. Many have gone many months, even up to a year, without receiving pay, which is kind of mind-boggling. One of the nurses explained to me that almost all the professional staff are very young, recently out of school, and from Monrovia (remember, a 10-12 hour bumpy drive away), because they are the only ones who have the flexibility to be able to work under these conditions, so far from home. It seems like the staff don't get paid largely because the Ministry of Health bureaucracy is slow and corrupt, and because Zwedru is so far from the capital that decision-makers never feel the impact of their work (or lack thereof).
The strike was very well organized and peaceful. The workers all showed up to work on Monday morning, stayed for an hour, and then left. Tuesday, they all came to the hospital, but had meetings under a tree outside all day. Eventually they concluded to go back to work on Wednesday, and reassess the situation after two weeks. Kerry invited one of us medical students up to the hospital to help out with patient care while the staff was out, so I went up to take vitals, which is a simple but necessary part of patient care, especially here, where vitals provide nearly half of the quantitative data that clinicians use to practice medicine. Vital signs are the body's most basic properties: temperature, pulse, respiratory rate, blood pressure, and oxygen saturation in blood. They are, well, vital. Here, I couldn't measure oxygen saturation because the hospital only has one machine, reserved for the operating room. In addition to vitals, they can spin down a hematocrit, or red blood cell count, do a blood smear looking for malaria, order a Widal test, which helps assess typhoid, and I think that's about it. We can't even order a basic metabolic panel here, i.e. levels of fundamental electrolytes like sodium, potassium, and chloride, to assess how a patient is doing. Raj said they used to be able to order these tests, and a few other basics, like liver function tests, a few years ago, but the machine broke, so they can't anymore. And no, there's no CD4 counter, so HIV patients are assessed clinically, by the WHO's standards, which is a pretty rough guide for care. In the US, these tests are, again, basic. We don't think twice about ordering them, and in fact have such a huge amount of hard data available to us that it can be overwhelming to sort through as a medical student.
One of the patients I saw had been in a motorbike crash the previous night and his face was swollen and cut up. We also don't have an x-ray machine here or an xray technician, so when I asked one of the docs how they assess for fracture without one, he replied, “physical exam.” Which translates to, “press on his face to feel if anything moves.” In the US, trauma patients like this are given lots of head imaging, e.g. xrays to look at bony deformities and CT to look for brain injury. The finest of fractures is noted in the radiology report, even if nothing needs to be done about it.
Later in the day, I was invited to watch a Caesarian section. Unfortunately, I didn't know much about the patient's case before I went into the operating room, but I think she had had prolonged and obstructed labor. In the US in this situation, the fetal heart rate is monitored to track how distressed the baby is, and that helps determine what needs to be done. Here (I was noticing a pattern), they don't have this equipment, and instead use a fetoscope, an instrument that I thought only existed in museums and old paintings. It is a trumpet-shaped tube that you put to a pregnant woman's belly and to your ear to hear the fetal heart beat. I didn't get a chance to use it, so I can't say how well it works, but just as comparison, the equipment I was trained with is a handheld doppler ultrasound. A quick search on Ebay showed that the machine costs $40 to $150: http://stores.ebay.com/MWM-Medical
Anyway, the OT, as the operating theatre is called, is the only room in the hospital with air conditioning, though it didn't work too well. I changed into scrubs, stepped in, and watched the surgeon and scrub nurse pull an infant out of the patient's belly. The baby came out with low APGAR scores, i.e. limp muscle tone, no cry, poor color, no grimace to stimulation. She looked terrible. I watched the nurse and the nurse anesthetist try and fail to resuscitate the baby. She died as her mother was sewn up. I'm not even sure if she ever lived.
I tried to normalize it. You see a lot of sad and terrible things in any hospital, and part of the experience involves accepting it and moving onto focus on the next patient. But in reflecting, I realized that I had never seen a baby die in my six weeks of obstetrics in the US, except one who had mysteriously died while still in utero at full term and had to be delivered dead. I couldn't take this one c-section as representative of anything, but it reminded me that childbirth is still a life-threatening experience-—for mom and baby-—in a lot of the world.
Most of my time here has actually not been in the hospital. I've been helping out with various things, including trotting along with the accompaniers for the past few days. We've been going out to find the depression patients who haven't come back to clinic in a while, ask them what's been keeping them, and encourage them to come back or go to one of the support groups. It's been great to get to know some of the accompaniers, who do the day to day work of TH. They are patient and empathetic and work hard in this hot hot sun. And they seem to know everyone in town while still maintaining confidentiality.
I'm half-thinking about writing a book called, “Hot, Dusty, Sweaty, and Thirsty,” where I live the life of a community health worker for a year to document its hardships, in the style of Barbara Ehrenreich. Ehrenreich wrote a booked called “Nickled and Dimed,” in which she spent a year pretending to be working class and writing about it, and she argued that working Americans are working really hard and being screwed despite their efforts. I wouldn't actually do it because I find the gimmick fundamentally kind of offensive (she could have just asked a bunch of working people what they thought), but it might have brought some attention to the plight of community health workers. As I alluded to in my last post about the Pool Fund, there's a big ideological divide in the international health community about whether these workers should be called workers (CHW's) or volunteers (CHV's), i.e. whether they should be paid. It is ludicrous that this question even arises, especially since their work is, as Raj terms it, “truly heroic.” Heroism aside though, people should be paid when they work, especially when they are hot, dusty, sweaty, and thirsty, and when their jobs require them to be kind to sick people in addition. It's not rocket science, and I'm sure most policy-making doctorates would go home the day their paychecks stopped. The sad thing is that paying CHW's would be so cheap here. It's $1600 a month (total!) to pay 40 people for part-time work at the national minimum wage. You could even double their salaries, pay them well for skilled and valuable work, and still it would be peanuts.
One of the other things I've been doing is helping with computers. I installed my anti-virus software on the county health information officer's computers a few days ago. I found 8000 infected files on one computer; it was pretty satisfying to clean that out. Just as there's a disproportionately high burden of infectious disease in people here, there is also a disproportionately high burden of infections in computers here. The other med students and I have also been teaching basic computer skills to the Liberians a few times a week. There's a big old digital divide. Teaching is feel-good here, since even the smallest computer-related thing is new information and ever-so-much appreciated.
Okay, I'm pooped. The fruit update is that I've made my tastes known to the neighborhood, and kids come by now with plums and occasionally po-po to buy. There's 4 kinds of plums here, but I've only tasted one so far. It's sweet and makes me happy.
Good night from under the mosquito net, safe from equatorial insects,
Roona
I'm sorry I've taken so long to write again. In the last few weeks, I've learned that living at the equator is physically exhausting, and I'm often too tired at the end of the day to write. The metabolic demand is higher, the nutritional quality of the food poorer, the economic availability of food crappier. It's hard even to keep up with my fluid balance, since I sweat so much everyday and getting clean water is a mild rigamarole. And I am a person of relative means. It is remarkable that people continue to exist here under conditions of poverty.
Which is not to say I haven't had a good couple of weeks. My first full week here was about adjusting physically to a new place and lifestyle (and temperature). I learned how the cell phones work (pre-paid cards, pretty good coverage, shitty battery life in my case); how to hail a motorcycle (“You riding?”); and that the best thing to eat is beans in bread from the lady who sells them outside the hospital and homemade guacamole.
My second full week has been about starting to get to know the people in the organization. I've met Philip, a patient in the HIV accompanier program who was resurrected from near death, social isolation, and suicidality from AIDS, when given HIV medicines, and is now Tiyatien's livelihoods officer. He is employed by the organization to counsel other patients on how to improve their social conditions and means. He is a visionary: with his new lease on life, he started a support group for people living with HIV/AIDS and a farm for them to work on because he believes that they must have a way to support themselves. I've met Agatha, a tall, part-Malian woman who is starting a center for local women where they can come and meet and learn the skills they want to learn. She has the land picked out already. And I've met Alphonso, who works nights as a nurse aide in the hospital and days running the accompanier program for Tiyatien. He supports eight family members, yet has an incredibly sweet and optimistic disposition. I'm not sure I would be so optimistic myself were I working under such demands. I've been interviewing some of these people for TH's website, and hopefully I'll be able to get those interviews online, whether in audio or transcribed format, soon. They'll give you a taste of Liberian English, which at first I had a hard time understanding, but now seem to have an ear for, at least some of the time.
It's been an eventful couple of weeks, too. Two Mondays ago, soon after I last wrote to you, the entire non-physician hospital staff went on strike. The physician assistants, nurses, nurse aides, pharmacists, cooks, security guards, housekeepers, everyone. So the doctors, Kerry and four others, went to the hospital, discharged the patients who could be discharged, and ran the rest of the show themselves, to preserve patient care. From placing IVs, to finding and dispensing medications, to taking vitals, and nearly to cleaning up vomit in the hallway. Not to say that they, and we, didn't sympathize with and support the strike. We did entirely. One of the docs sometimes works for months without receiving pay because he's on government payroll, and he served as a negotiator for the striking staff. An unreliable paycheck is one of the main issues underlying the state of the healthcare system here, and the strike helped get the government in Monrovia to pay (some) attention.
Hospital strikes here are unusual. Raj says he's never seen one in the 4 years he's been coming to Zwedru, although they came close to striking a few years ago. Their demands were pretty straightforward: they wanted year-long contracts and to be paid and paid on time. Currently, they work without a contract, which means they have no job security and no proof of the terms of their employment. Many have gone many months, even up to a year, without receiving pay, which is kind of mind-boggling. One of the nurses explained to me that almost all the professional staff are very young, recently out of school, and from Monrovia (remember, a 10-12 hour bumpy drive away), because they are the only ones who have the flexibility to be able to work under these conditions, so far from home. It seems like the staff don't get paid largely because the Ministry of Health bureaucracy is slow and corrupt, and because Zwedru is so far from the capital that decision-makers never feel the impact of their work (or lack thereof).
The strike was very well organized and peaceful. The workers all showed up to work on Monday morning, stayed for an hour, and then left. Tuesday, they all came to the hospital, but had meetings under a tree outside all day. Eventually they concluded to go back to work on Wednesday, and reassess the situation after two weeks. Kerry invited one of us medical students up to the hospital to help out with patient care while the staff was out, so I went up to take vitals, which is a simple but necessary part of patient care, especially here, where vitals provide nearly half of the quantitative data that clinicians use to practice medicine. Vital signs are the body's most basic properties: temperature, pulse, respiratory rate, blood pressure, and oxygen saturation in blood. They are, well, vital. Here, I couldn't measure oxygen saturation because the hospital only has one machine, reserved for the operating room. In addition to vitals, they can spin down a hematocrit, or red blood cell count, do a blood smear looking for malaria, order a Widal test, which helps assess typhoid, and I think that's about it. We can't even order a basic metabolic panel here, i.e. levels of fundamental electrolytes like sodium, potassium, and chloride, to assess how a patient is doing. Raj said they used to be able to order these tests, and a few other basics, like liver function tests, a few years ago, but the machine broke, so they can't anymore. And no, there's no CD4 counter, so HIV patients are assessed clinically, by the WHO's standards, which is a pretty rough guide for care. In the US, these tests are, again, basic. We don't think twice about ordering them, and in fact have such a huge amount of hard data available to us that it can be overwhelming to sort through as a medical student.
One of the patients I saw had been in a motorbike crash the previous night and his face was swollen and cut up. We also don't have an x-ray machine here or an xray technician, so when I asked one of the docs how they assess for fracture without one, he replied, “physical exam.” Which translates to, “press on his face to feel if anything moves.” In the US, trauma patients like this are given lots of head imaging, e.g. xrays to look at bony deformities and CT to look for brain injury. The finest of fractures is noted in the radiology report, even if nothing needs to be done about it.
Later in the day, I was invited to watch a Caesarian section. Unfortunately, I didn't know much about the patient's case before I went into the operating room, but I think she had had prolonged and obstructed labor. In the US in this situation, the fetal heart rate is monitored to track how distressed the baby is, and that helps determine what needs to be done. Here (I was noticing a pattern), they don't have this equipment, and instead use a fetoscope, an instrument that I thought only existed in museums and old paintings. It is a trumpet-shaped tube that you put to a pregnant woman's belly and to your ear to hear the fetal heart beat. I didn't get a chance to use it, so I can't say how well it works, but just as comparison, the equipment I was trained with is a handheld doppler ultrasound. A quick search on Ebay showed that the machine costs $40 to $150: http://stores.ebay.com/MWM-Medical
Anyway, the OT, as the operating theatre is called, is the only room in the hospital with air conditioning, though it didn't work too well. I changed into scrubs, stepped in, and watched the surgeon and scrub nurse pull an infant out of the patient's belly. The baby came out with low APGAR scores, i.e. limp muscle tone, no cry, poor color, no grimace to stimulation. She looked terrible. I watched the nurse and the nurse anesthetist try and fail to resuscitate the baby. She died as her mother was sewn up. I'm not even sure if she ever lived.
I tried to normalize it. You see a lot of sad and terrible things in any hospital, and part of the experience involves accepting it and moving onto focus on the next patient. But in reflecting, I realized that I had never seen a baby die in my six weeks of obstetrics in the US, except one who had mysteriously died while still in utero at full term and had to be delivered dead. I couldn't take this one c-section as representative of anything, but it reminded me that childbirth is still a life-threatening experience-—for mom and baby-—in a lot of the world.
Most of my time here has actually not been in the hospital. I've been helping out with various things, including trotting along with the accompaniers for the past few days. We've been going out to find the depression patients who haven't come back to clinic in a while, ask them what's been keeping them, and encourage them to come back or go to one of the support groups. It's been great to get to know some of the accompaniers, who do the day to day work of TH. They are patient and empathetic and work hard in this hot hot sun. And they seem to know everyone in town while still maintaining confidentiality.
I'm half-thinking about writing a book called, “Hot, Dusty, Sweaty, and Thirsty,” where I live the life of a community health worker for a year to document its hardships, in the style of Barbara Ehrenreich. Ehrenreich wrote a booked called “Nickled and Dimed,” in which she spent a year pretending to be working class and writing about it, and she argued that working Americans are working really hard and being screwed despite their efforts. I wouldn't actually do it because I find the gimmick fundamentally kind of offensive (she could have just asked a bunch of working people what they thought), but it might have brought some attention to the plight of community health workers. As I alluded to in my last post about the Pool Fund, there's a big ideological divide in the international health community about whether these workers should be called workers (CHW's) or volunteers (CHV's), i.e. whether they should be paid. It is ludicrous that this question even arises, especially since their work is, as Raj terms it, “truly heroic.” Heroism aside though, people should be paid when they work, especially when they are hot, dusty, sweaty, and thirsty, and when their jobs require them to be kind to sick people in addition. It's not rocket science, and I'm sure most policy-making doctorates would go home the day their paychecks stopped. The sad thing is that paying CHW's would be so cheap here. It's $1600 a month (total!) to pay 40 people for part-time work at the national minimum wage. You could even double their salaries, pay them well for skilled and valuable work, and still it would be peanuts.
One of the other things I've been doing is helping with computers. I installed my anti-virus software on the county health information officer's computers a few days ago. I found 8000 infected files on one computer; it was pretty satisfying to clean that out. Just as there's a disproportionately high burden of infectious disease in people here, there is also a disproportionately high burden of infections in computers here. The other med students and I have also been teaching basic computer skills to the Liberians a few times a week. There's a big old digital divide. Teaching is feel-good here, since even the smallest computer-related thing is new information and ever-so-much appreciated.
Okay, I'm pooped. The fruit update is that I've made my tastes known to the neighborhood, and kids come by now with plums and occasionally po-po to buy. There's 4 kinds of plums here, but I've only tasted one so far. It's sweet and makes me happy.
Good night from under the mosquito net, safe from equatorial insects,
Roona
Tuesday, April 13, 2010
12 April 2010
Dear Friends,
It's 11 pm, and I'm sitting cozy under my mosquito net at the Tiyatien Guesthouse in Zwedru, Liberia, listening to UNMIL (UN Mission in Liberia) radio on my headphones, typing away by my laptop's battery power (we don't have electricity here at the guesthouse). It's the only FM radio I can get here. The debate on the radio tonight is heavy: it regards why Liberia is one of the richest countries in the world, in terms of natural resources, but one of the poorest, in terms of economic, health, and social indicators. Some facts I've learned in the last week: the country has 85% unemployment, 40% literacy, and an average of 5.2 children born to each woman of reproductive age. Clearly, this question has stymied many people—-Liberians and foreigners alike—-before me. I doubt I'll find any answers in my short stay here, but I hope I'll be able to communicate some of my observations and experiences in my first visit to Liberia.
I arrived in Monrovia, the capital city, a week and a half ago with my friend from public health school, Raj, who is a medicine resident in Boston, and a medical student from Chicago, Justin. There, we met up with another medical student from Boston, Ana, as well as Kerry, an attending internal medicine doctor who has spent most of the last year—-her first year out of residency—-here in Liberia. We spent a few days in Monrovia (which drained our wallets) meeting with various Tiyatien supporters, funders, and key contacts in the governmental- and non-governmental health community there. The health sector is currently a trophy of Liberia; common knowledge is that it is the best funded and performing sector in the country. So it was fascinating and educational to have the opportunity to interact with various players in the community—-governmental bodies, international health service delivery organizations, and international non-governmental funding organizations—-and to think about the role of a community-based organization like ours, in this setting. Yet it was sobering to remember that there are only an estimated 50-120 doctors in this country of 3 million. At times, during some of our meetings, I would look around and calculate the (large) percentage of the country's physicians sitting around the table.
We spent Tuesday traveling to Zwedru. We took a Land Rover for four hours by pitted (but paved) road, stopped for lunch in Ganta, and then continued for another six hours by (very) bumpy red dirt road. Luckily, the weather has been dry, so the road was not muddy, as it is in the rainy season, for had it been, the trip would have been much longer. Raj has been to Zwedru now more than ten times. (He is Liberian and started this organization with survivors of the war when he was a medical student.) One of those trips was by small plane. Remarkably, he told us that the trip by air takes only 45 minutes; it is approximately 200 miles, as the crow flies, or about the distance from Boston to New York.
My days in Zwedru start with Jatu waking me up through the window. She is a young woman, about 23, who does our cooking and housework for us, which is a blessing, because cooking by charcoal stove in 95 degree humidity is hard work, even for those of us who like to cook. The food here generally involves some kind of fried spicy greens (potato, cassava, or water greens) and what Liberians call “soup,” but I would call more of a curry, i.e. a meat or fish dish with a rich gravy, or mashed spicy beans, all served with rice. I've been on a hunt for fruit, but aside from bananas, it is surprisingly hard to find in the markets. The landscape here is extremely lush, hot, and humid. There are papaya and mango trees everywhere, pineapples, oranges, and rice paddies are not uncommon, and I think I've spotted red ginger plants. Despite the climate, agriculture is not as big I would have thought. Historically, this has been predominantly a hunter-gatherer society, and accordingly, the diet is heavy in meat, bush cow, deer, pig, chicken, and yes, monkey. Additionally, it sounds like the war, which ended about 7 years ago, destabilized communities and agricultural knowledge, and created a day-to-day mentality that makes it hard to plan ahead enough to farm. Raj says that many of the small farms that we see around town and on the road here did not exist just one or two years ago.
I met our neighbor a few days ago because he has a papaya tree heavy with green papayas that I was hoping he'd sell to me when they become ripe. He taught me about the microeconomics of farming here. He is a farmer who seems to be doing decently. He lives with his extended family in a series of mud brick and zinc or thatch roofed houses. (Corrugated zinc roof is the fanciest kind of roof here, with the other options being thatch or tarp. By comparison, our house is made of cement with a zinc roof). He has a farm that is a 75 Liberian dollar motorbike ride out of town, which I'm estimating, is 10-15 miles or so. He says he grows oranges, plums (mangoes), po-po (papaya), butter pear (avocado), and other fruits and vegetables. This sounds delicious to me, but he says he's trying to get into rubber farming. There's only one person in this area who does it, and the rubber company, Firestone, drives through our county (Grand Gedeh) to get to an even more distant place, Maryland county, for rubber. (More later, if I learn about it, but Firestone has a long history of exploiting and exporting rubber from Liberia, producing tires elsewhere, and selling them in yet other places.) He thinks if he can get some rubber going, he'll head off those people in Maryland and have a profitable crop. Rubber, he tells me, grows year round, whereas fruits and vegetables are seasonal. I get it, but hope he doesn't make the switch too soon, so maybe I can get some fruit while I'm here.
In terms of Tiyatien's work, it feels like we've arrived at a pivotal time, just as the Pool Fund is taking off in Grand Gedeh county. The Pool Fund is a new mechanism for facilitating the funding of health aid work that is meant to foster coordinated healthcare delivery and funding between governmental, international, and local partners. On our first day in Zwedru, we attended the kick-off meeting between the county's Pool Fund partners—the county health team (a local branch of the Ministry of Health), Merlin (a UK-based NGO that has been in the region since 1999), and Tiyatien Health (we're the local NGO because of our community-member driven mission). The county health officer described the Pool Fund well: he called it “A big basket that everyone is chipping into.” Like the international Global Fund, which centralizes aid money for AIDS, malaria, and TB from many donor countries, the Pool Fund collects health aid money for Liberia from various foreign governments, such as the UK, Germany, and Norway (but interestingly, not the US), at the national level at the Ministry of Health, which then determines the guidelines for how to spend the money and awards it to counties. One of the requirements the MoH put on county-level proposals was that they must partner government, international, and local NGOs. So with the MoH centrally collecting and distributing aid money and setting the criteria for health development, and local players having to coordinate, theoretically, there is a new, collaborative, unified system, instead of the prior system in which various health care delivery organizations in effect competed with each other, and did not coordinate efforts, leading to wasted energy and money in a setting that cannot afford it. Theoretically.
Crap. I think some bugs have managed to get into my mosquito netted haven. I'm going to have to shut the computer off so they don't continue flocking to the light. But next time, I'll tell you how the Pool Fund is changing the day to day of TH and healthcare delivery at the county level in general. And I'll tell you about some of the problems it raises. I'll also keep you updated regarding whether I actually get to eat some of the hundreds of mangoes that are hanging off my neighbor's tree.
Wishing you a mosquito free night,
Roona
P.S. I've spent several hours of the last week entering data from our Community Health Living Survey, and I've learned that almost no one in Grand Gedeh county uses a mosquito net, though this is a malaria-endemic area. Someone call Jeff Sachs, the economist who was on a personal mission to get mosquito nets to Africa, and ask him to send some to Zwedru.
Dear Friends,
It's 11 pm, and I'm sitting cozy under my mosquito net at the Tiyatien Guesthouse in Zwedru, Liberia, listening to UNMIL (UN Mission in Liberia) radio on my headphones, typing away by my laptop's battery power (we don't have electricity here at the guesthouse). It's the only FM radio I can get here. The debate on the radio tonight is heavy: it regards why Liberia is one of the richest countries in the world, in terms of natural resources, but one of the poorest, in terms of economic, health, and social indicators. Some facts I've learned in the last week: the country has 85% unemployment, 40% literacy, and an average of 5.2 children born to each woman of reproductive age. Clearly, this question has stymied many people—-Liberians and foreigners alike—-before me. I doubt I'll find any answers in my short stay here, but I hope I'll be able to communicate some of my observations and experiences in my first visit to Liberia.
I arrived in Monrovia, the capital city, a week and a half ago with my friend from public health school, Raj, who is a medicine resident in Boston, and a medical student from Chicago, Justin. There, we met up with another medical student from Boston, Ana, as well as Kerry, an attending internal medicine doctor who has spent most of the last year—-her first year out of residency—-here in Liberia. We spent a few days in Monrovia (which drained our wallets) meeting with various Tiyatien supporters, funders, and key contacts in the governmental- and non-governmental health community there. The health sector is currently a trophy of Liberia; common knowledge is that it is the best funded and performing sector in the country. So it was fascinating and educational to have the opportunity to interact with various players in the community—-governmental bodies, international health service delivery organizations, and international non-governmental funding organizations—-and to think about the role of a community-based organization like ours, in this setting. Yet it was sobering to remember that there are only an estimated 50-120 doctors in this country of 3 million. At times, during some of our meetings, I would look around and calculate the (large) percentage of the country's physicians sitting around the table.
We spent Tuesday traveling to Zwedru. We took a Land Rover for four hours by pitted (but paved) road, stopped for lunch in Ganta, and then continued for another six hours by (very) bumpy red dirt road. Luckily, the weather has been dry, so the road was not muddy, as it is in the rainy season, for had it been, the trip would have been much longer. Raj has been to Zwedru now more than ten times. (He is Liberian and started this organization with survivors of the war when he was a medical student.) One of those trips was by small plane. Remarkably, he told us that the trip by air takes only 45 minutes; it is approximately 200 miles, as the crow flies, or about the distance from Boston to New York.
My days in Zwedru start with Jatu waking me up through the window. She is a young woman, about 23, who does our cooking and housework for us, which is a blessing, because cooking by charcoal stove in 95 degree humidity is hard work, even for those of us who like to cook. The food here generally involves some kind of fried spicy greens (potato, cassava, or water greens) and what Liberians call “soup,” but I would call more of a curry, i.e. a meat or fish dish with a rich gravy, or mashed spicy beans, all served with rice. I've been on a hunt for fruit, but aside from bananas, it is surprisingly hard to find in the markets. The landscape here is extremely lush, hot, and humid. There are papaya and mango trees everywhere, pineapples, oranges, and rice paddies are not uncommon, and I think I've spotted red ginger plants. Despite the climate, agriculture is not as big I would have thought. Historically, this has been predominantly a hunter-gatherer society, and accordingly, the diet is heavy in meat, bush cow, deer, pig, chicken, and yes, monkey. Additionally, it sounds like the war, which ended about 7 years ago, destabilized communities and agricultural knowledge, and created a day-to-day mentality that makes it hard to plan ahead enough to farm. Raj says that many of the small farms that we see around town and on the road here did not exist just one or two years ago.
I met our neighbor a few days ago because he has a papaya tree heavy with green papayas that I was hoping he'd sell to me when they become ripe. He taught me about the microeconomics of farming here. He is a farmer who seems to be doing decently. He lives with his extended family in a series of mud brick and zinc or thatch roofed houses. (Corrugated zinc roof is the fanciest kind of roof here, with the other options being thatch or tarp. By comparison, our house is made of cement with a zinc roof). He has a farm that is a 75 Liberian dollar motorbike ride out of town, which I'm estimating, is 10-15 miles or so. He says he grows oranges, plums (mangoes), po-po (papaya), butter pear (avocado), and other fruits and vegetables. This sounds delicious to me, but he says he's trying to get into rubber farming. There's only one person in this area who does it, and the rubber company, Firestone, drives through our county (Grand Gedeh) to get to an even more distant place, Maryland county, for rubber. (More later, if I learn about it, but Firestone has a long history of exploiting and exporting rubber from Liberia, producing tires elsewhere, and selling them in yet other places.) He thinks if he can get some rubber going, he'll head off those people in Maryland and have a profitable crop. Rubber, he tells me, grows year round, whereas fruits and vegetables are seasonal. I get it, but hope he doesn't make the switch too soon, so maybe I can get some fruit while I'm here.
In terms of Tiyatien's work, it feels like we've arrived at a pivotal time, just as the Pool Fund is taking off in Grand Gedeh county. The Pool Fund is a new mechanism for facilitating the funding of health aid work that is meant to foster coordinated healthcare delivery and funding between governmental, international, and local partners. On our first day in Zwedru, we attended the kick-off meeting between the county's Pool Fund partners—the county health team (a local branch of the Ministry of Health), Merlin (a UK-based NGO that has been in the region since 1999), and Tiyatien Health (we're the local NGO because of our community-member driven mission). The county health officer described the Pool Fund well: he called it “A big basket that everyone is chipping into.” Like the international Global Fund, which centralizes aid money for AIDS, malaria, and TB from many donor countries, the Pool Fund collects health aid money for Liberia from various foreign governments, such as the UK, Germany, and Norway (but interestingly, not the US), at the national level at the Ministry of Health, which then determines the guidelines for how to spend the money and awards it to counties. One of the requirements the MoH put on county-level proposals was that they must partner government, international, and local NGOs. So with the MoH centrally collecting and distributing aid money and setting the criteria for health development, and local players having to coordinate, theoretically, there is a new, collaborative, unified system, instead of the prior system in which various health care delivery organizations in effect competed with each other, and did not coordinate efforts, leading to wasted energy and money in a setting that cannot afford it. Theoretically.
Crap. I think some bugs have managed to get into my mosquito netted haven. I'm going to have to shut the computer off so they don't continue flocking to the light. But next time, I'll tell you how the Pool Fund is changing the day to day of TH and healthcare delivery at the county level in general. And I'll tell you about some of the problems it raises. I'll also keep you updated regarding whether I actually get to eat some of the hundreds of mangoes that are hanging off my neighbor's tree.
Wishing you a mosquito free night,
Roona
P.S. I've spent several hours of the last week entering data from our Community Health Living Survey, and I've learned that almost no one in Grand Gedeh county uses a mosquito net, though this is a malaria-endemic area. Someone call Jeff Sachs, the economist who was on a personal mission to get mosquito nets to Africa, and ask him to send some to Zwedru.
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