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.