After only two days in Monrovia and barely acclimatized to the culture, The MENTOR team set off to Zwedru – a 20,000+ town near the Sierra Leone border to review one of the sentinel sites. This sentinel site is a major Ministry of Health funded hospital which reports on malaria cases through MENTOR cooperation. The hospital is also co-funded by MERLIN.
Planning to leave at 7am, the driver was not ready and we left closer to 8am. Though it seems like a minor delay, time is crucial when heading out into the field or “the bush” as it is called. Darkness is not a favourable place to be.
The damaged paved roads are lined with a red ferrous shoulder but soon the shoulder became the road and the black of asphalt is replaced by deeply pitted holes while red dust is carried through the car windows to cake our skin and clothes. The dust reminds me of travelling through the Australian outback but, unlike the outback, there are many mud huts, houses with zinc corrugated roofs and a littering of defunct and broken down cars. Many cars lined the roadside and stripped of everything but their frame but there are many others which were newly broken down with hordes of passengers gathering around the cars and trucks to make desperate attempts to repair their vehicles and keep moving. The vehicle that we were in was a Land Rover – strong and built to manage the harsh jungle environment. With me was the driver, Raymond, our resident doctor from the Philippines, Bet Bet and two national staff members Buster, the IT manager, and Caroline, an administrative coordinator. The Land Rover barrelled through the pot holes in the road as the passengers were tossed around like a terrible ocean storm. We passed many banana, rice and rubber plantations. The rest of the countryside was more endless jungle.
We stopped once for lunch where I managed to eat a local meal – cow meat soup (‘beef’ not being a term used here). This is my first experience with this dish and, as I would learn later on, this one was actually quite good unlike future soups I would have where the meat would be gristly and difficult to chew. The standard fare is four pieces of meat, generally two made mostly of bone, a meat sauce that is heavy on the palm oil and a large serving of rice. At the end, you basically eat the sauce-soaked rice and do your best to take in whatever meat is served. There are usually only two dishes served at any restaurant and you can only get food when the sign on the door says “food is ready”. If not, food is not ready. Meat is not refrigerated but salted if you are lucky. A gruelling 6 hours to lunch lead to another gruelling six hours until we reached the hotel. Night was falling and the security risk goes up. It was possible that we could have been carjacked but this time had no trouble.
Throughout the ride, we often got stopped by roadblocks. Some of them were official but these blocks were only to check on commercial trucks to see if any contraband was moving though the county and possibly to get a bribe to pass. These roadblocks varied in quality with some being actual dropdown gates to a series of badly broken orange pylons to just a string that is being held by a tree and loosened to allow the cars to drive over them. As well, there are United Nations (UN) roadblocks for security reasons. The UN is a strong presence here as well as other major international organizations. This is a failed state – a country whose government cannot manage to keep order.
We passed two major places of interest. The first was the Firestone Plantation where, I have heard, those that live there are living better than the rest of the population and, second, the Coca-cola factory. With little other food production going on in the country, I suspect I will be drinking a lot of cola here as it is being produced locally.
The hotel we arrived at was considered a multi-star hotel but by how many stars I don’t know. One night usually costs about $50 USD but we get a regular discount at $25 – more than the typical monthly salary for a Liberian. The electricity was irregular at best as the sick and ancient generator struggled to provide any power. The air conditioner turned off and the stifling humidity crept into the room again. Without power, the water pumps cannot push water through the pipes and a bucket shower is the only means of removing the several layers of red dust that has glued to my skin. As with all the places that I go to, the walls that surround the hotel are high and topped with razor wire. The gate is guarded by many security staff.
As a side note, I have never become used to bucket showers. Even in the hottest climates, I find the room temperature bucket water still too cold. Of all the things I need to get used to, I think this is lowest on my list.
The night is dark without electricity and, exhausted, I headed to bed dreaming of a time when everything you needed was just down the street in a dollar store.
The next morning we headed to the hospital. This is the sentinel site that documents our malaria cases. I met Michael, the Country Director, for the first time since I arrived in Liberia and we begin to review the books. These books are ledgers which summarize basic elements of the clinical notes for each department such as the maternity ward or out-patients. The hospital is badly in need of streamlining. There are many points of entry for a patient into the hospital which can cause potential confusion over where a patient should end up. In fact, there is little distinction between what is normally called Triage, the first place a patient goes to seek help, and the Emergency Room. The team moves around the hospital, from out- to in-patients (separated by gender), and in-patient and out-patient pharmacy, through the maternity ward, across to the clinical notes registry (where the clinical notes are stored), laboratories and finally to the store rooms (one Ministry of Health run and the other managed by MERLIN) where drugs and other equipment are kept. All these places are important sources of malaria data.
In terms of malaria monitoring, you want to see how a few key indicators are changing over time. First, you want to see how many people are being diagnosed with malaria. Next, a sub-demographic of the most vulnerable groups, pregnant women and children under five, are diagnosed at the hospital. There is also consumption data that needs to be considered – how much anti-malarial drugs are being used, which ones are being taken and how all of this is changing over time. From what we can see, the way that they are managing their data, by using a tally sheet to count all the malaria cases, seems redundant. My work in the future will be to optimize the flow of data and create easier and high quality data systems for the staff members, data entry clerks and data analysis.
We met nurses and doctors, medical directors and even, briefly, the chief medical officer. We had a group meeting with all the staff to discuss how to improve operations but mostly to discuss how to incentivize their work while not increasing the burden of their workload. For any Liberian institution to work, a pay-for-performance scheme needs to be in place but I will discuss the basics of human motivation in a later post as it relates to Liberian culture. As with all meetings I have experienced (both in African and anywhere else), a small gift of food is enough to push people to attend which, in this case, was a tuna fish sandwich on white bread with a soft drink. Though the staff didn’t seem terribly encouraged, the meeting went well and some small progress is being made here.
As a side note, I think everything here is done with song. We started our meeting with a thank you from several people for taking part in the meeting and a chorus song of prayer to Jesus which was sung in wonderful harmony.
All in all, with little steps, things will get better but it will take both sides working together to make this work.
Zwedru is a surprisingly nice city. Still, like Monrovia, people still live in straw and thatch huts and some have zinc corrugated roofs. The streets are well paved and there are signs that this town was once on the way up towards modernity with streetlamps over the main boulevard but now they are just wonky derelict relics of a very hopeful future.
After a lengthy two days moving around Zwedru, we prepared ourselves to go. This time, instead of the heading the long route, I got to fly…
Now, flying in a UN helicopter was never one of those things I put on my life list but the moment I heard that this was the way we were getting back to Monrovia, I instantly added it right behind dancing to ABBA in Sweden under a midnight sun. After a long painful wait, since we were on the waiting list, we got on the flight. After walking in with UN soldiers from Bangedesh, Pakistan and China along with politicians and NGO reps, we took off. The entire flight was two hours and stopped at several locations. The Ukrainian pilots were incomprehensible but I think they said to put on your seatbelt but no mention of where the emergency exists were. No in flight meal either. This is one of the coolest things I have ever done next to the Tibetan Sky Burial. Life list item: fly in a UN helicopter – check!
Home sweet home and I am back in Monrovia to relax for the weekend. There was a lot to absorb in my first trip to the field. There will be more – many more. Already, Liberia is nothing short of an adventure.
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