My first operation.

Earlier this week I observed my first operation.
I was a bit trepidatious about the whole matter, but I have resolved
that, if this is something I want to think about long term (working
with MSF), I should become familiar - through proximity - to the sorts
of things that go on in the project every day. Since Liberia is a
pretty stable country, I don't see a lot of gun shot victims or
anything on base. I thought it a good idea to start watching
procedures be done.

In this case, my first procedure was pretty minor. It was, I
understand, a "re-laporotomy". A woman (girl) had had C-section a week
ago, but her abdomen was getting larger and painful. The ultrasound
was not clear if it was infected, blood, or a mass, and the doctors
couldn't really tell be touch, so they decided to 'open her up' again
to find out what the problem was.

As it turns out, it was an infection, and needed extensive drainage.

But for me, it was my first OR procedure!

Some thoughts: not as bad as I thought it would be, very little
stomach turning or gag reflex. The masks you have to wear, combined
with being on your feet, combined with being in Liberia, definitley
made me light headed at times (from overheating and breathing through
the damn thing), but didn't pass out and didn't vomit. All told I
think that I did pretty good for witnessing my first ever live human
being be cut open in front of me. What was striking for me was how the
whole thing works. I mean, on one side of the gown the patient is
awake, with a 'ketamine block'(?), lying there, bored, even getting
chilly and yawning. On the other side, out of view, the surgeon has
her abdomen cut about 10 inches, all the way through, and is just
going at it to get the drainage complete before putting in the
drainage tubes. The whole thing is a little bit surreal, or it was for
me anyway.

To follow up, I went in to the hospital for an assessment on an
emergency case where an individual had managed to get their whole hand
into a cane mill. A motorized cane mill. The hand was thoroughly
crushed, and to make it better the individual had visited a
'traditional healer' who said that he would be able to keep it, but
she took out bone fragments to put back in for better healing later
(!). Severe avulsion (I think that's the word), mushed fingers, the
whole deal. It was a mess.

I contemplated sticking around for the surgery...but in the end
decided I should take it slow. The determination was made to amputate
four fingers. Part of me wishes I had stayed to watch, but I'm really
not sure I could do it yet. How do you know if you can stomach
watching fingers be cut off with a saw? What do I do if I can't? What
does it mean if I can? A whole lot of things I need to think about.
Maybe I'll go next time.

ciao for now-
taj

I was not appropriately briefed...

Wow. No, really. Wow.

Earlier this week I made my first visit to Lugbeye clinic. For those keeping score, that means I’ve so far managed to visit two of four clinics I am responsible for. Yay, me!
Lugbeye (loog-bee-yee) clinic is located right on the top corner of Nimba county, a stone’s throw from Guinea. It’s a town (village?) of approximately 3500 people. Why was I going to Lugbeye? Well, for one, I’m responsible for the clinic that’s currently there. It’s a tiny, mud-brick building of maybe 6 rooms with a latrine, and placenta, sharps, and burn pits out back. It’s tiny, hot, dark, and the doors are only about 5 feet tall. Ouch.
But really the reason I went is because I have to build a new clinic. Yep. I get to build a totally new clinic from the ground up in Lugbeye. It’ll be about 14 rooms, approximately 250 square meters. It’s quite exciting, really.

But that’s not why I said “wow.”

No, I said “wow” because, as I alluded to in the title of this post, and as I remarked to my Project Coordinator during my visit, I was not appropriately briefed.

So, some backstory?

Any time you visit a village, you need to speak with the head man (chief) of the village. In this case, we had wanted to do a quick visit of the clinic and prospective site for the new clinic and then be gone. So we sent one of our outreach team to talk to the chief the day before and let him know we are coming.

Now, the part that we didn’t think about was who was coming. In this case, the visit consisted of an outreach worker (Florence), a doctor (Daniel), the project coordinator (Annette), myself (me), and then not one but TWO head-of-missions. Both Sebastian (outgoing HoM), and Christian (incoming HoM), were also tagging along.

Apparently, the head man for the town received this information and decided that he had the Lugbeye equivalent to the President of the United States visiting. Really.

We managed to enter the town with a minimum of fanfare, and made it to the clinic without incident. As we were inspecting the existing latrines, our ears perked up. Was that drumming (sangba)? Huh. Well, ok, off to the sharps pit.

In truth, it was sangba. Three guys were walking along the path to the clinic. OK. But then a crowd started to appear. Then more of a crowd. Then even more. Then the head man. He came along and told us that we would begin the program down at his house.

Program?

OK, we’ll walk to the head man’s house.

By this time, pretty much the whole village has come out to greet us. Sangba players are playing, and women are singing, dancing, children laughing, we’re surrounded. And so we begin a parade through town, escorted by the head man and Officer In Charge (clinic administrator). And it really is a parade…We move at a snail’s pace, shuffling our feet. As we walk, women are bent over in front of us with scarves, brushing off the ground we are about to tread upon. Behind us come the drum players, singing and beating out rhythm. In front of us are two women carrying a long scarf, held between them, to make sure no one got too close to us. People were waving, smiling, wanting to shake our hands. About halfway into the walk, a traditionally garbed woman appeared, in full regalia, to dance in front of us the remainder of the distance. We walked past the schoolchildren, all gathered together, singing a song. The 100 meter walk took approximately 45 minutes.

Then we arrive at the head man’s house. Here, apparently, the program can begin!

It was a full agenda. Of course, we were all seated outside on the ‘veranda’ so the whole town could gather around to watch. It was kicked off with a prayer, led by the town priest. Then, the opening ceremonies, including introductions of everyone from both sides (all expats, the headman, the OIC, the priest, the village elders, etc). Of course, this had to be done in both English and Manu. Then the introductory statements from the head man, the OIC, and our Head of Mission (he wasn’t appropriately briefed either J ).

Then they introduced the school choirs. There are two ‘schools’ in Lugbeyee, one Baptist, one something else. They were obliged to perform two songs for us in front of this tremendous crowd. That was really, really nice. They did a great job.

After that, I think (things start to run together now), we had a traditional sharing of a kola nut. Then our Project Coordinator (Annette) was presented with a billy goat for bringing this new clinic to the town. Then there was more fancy talk for the crowd. Then we talked a little business. Then we concluded the agenda with another prayer. Then, finally, we could go to the planned ‘construction’ site.

Well, except that we had to do that in processional as well. At least now they stopped cleaning the ground in front of us, they took down the scarf, and we could walk at a more normal pace. But still the drum players were at it, and the dancer led the way, and the whole town went to the site with us.

So we looked at the site, the new head of mission and myself, with the outgoing head of mission and Annette drawing off the crowds a little bit so we could get some things done. We had to measure, plan, discuss, etc.

Then they wanted to know when we could start building. Yikes! We don’t even have a plan yet! We settled that we would have a meeting with the town Clinic Construction Committee (22 members) right then to discuss the plan. We ask them, “do you have a plan?” “Yes, we already have a plan.” Oh, well, then, ok…let’s talk plans! Before we enter into a meeting for this, they need to talk amongst themselves about the plan again, to make sure they’re all on the same page, maybe?

They needed about 25 minutes to discuss their plan for the clinic. It was a very vociferous talk, much gesticulating, much jumping up and down. Finally, they were ready to talk about the plan.

Which, of course, means we have to walk back to the head man’s house. In procession. Thankfully, Annette and Sebastian have still drawn off the bulk of the crowd, so it’s only the dancer, drummers, a couple dozen committee members, and three or four dozen villagers.

The meeting, of course, requires yet another round of introductions. Once those were done, we said “OK, so your committee has talked about the plan?” “Yes. We have talked about the plan.” They’ve taken almost a half hour to talk about the plan. “So. What type of plan have you come up with for this clinic?” A long, long pause. Then, the chairman of the committee reaches out with his hand, puts it on my knee. “Well, we have decided that your plan is very much our plan. So, why don’t you tell us your plan, and then we can discuss it.”

Ah.

We shared our plan. It was, as far as they were concerned, a perfect plan.

*sigh*

Then we could wrap up the meeting, I agreed to come out again next Monday and have a draft of the plan on paper for the work to start. They will keep making mud bricks in my absence.

Finally, hours later, we are ready to go back to the land cruiser. Well, we’re ready to start back to the land cruiser. Of course, we can’t just walk back, we have to be led. Drummers come back out, the traditional dancer leads the way…Along the way back, the dancer ‘challenges’ us – while the drummers are going, she clears a space, moves up front, and performs some sort of traditional dance back to us (where we’ve been obliged to stand and wait). At first, honestly, it’s quite intimidating…Mostly, for me, only because I don’t know what the proper response should be. Do I just stand and watch? Do I respond in some way? The whole village is watching! Eep!

I settled on responding by mostly standing there, but when she finished her dance, I initiated one of my own. J If you remind me, I have the last part of the dance in a movie file…My HOM was too slow to get the whole thing, but he got the last bit.

The best part about it was when I started to dance, the village absolutely erupted with cheering. It was downright deafening. Honestly, I think I looked quite foolish, trying to imitate her dance while wearing my MSF T-shirt and carrying a big red backpack, but apparently, in the eyes of the townspeople, I got points just for trying. It felt really nice.

So, eventually, they got the goat strapped to the top of the truck, and we could trundle off.

It was an interesting day…I was not appropriately briefed for this visit. The highlights, for me? For the first time, I got to hear some real drumming. I got to see a traditional dancer. I got to visit a village where no one speaks English (they all spoke Manu). For the first time, I really felt like I was in Africa.

And it was great.

Interesting News?

Not really.
Sorry to leave anyone hanging on the end of the earlier post. As I was
sitting typing in Hotel Base in Monrovia, I was informed by security
that on the FM radio the news was saying 6 people had died in Nimba
(where Sangba base is) and that they had eaten chicken. It also said
they had bled heavily from the nose and mouth. This of course meant
lots of phone calls and satellite calls and confirm/deny and
surveillance officers being sent out and all kinds of things!

Bird Flu is a huge issue facing Western Africa right now. Nigeria's
only a country away from us here and lots and lots of people rely on
poultry for food. Walking through Sanniquellie there's a constant din
of squawking chickens, crying roosters, honking ducks, etc.

If bird flu were to make the jump to Liberia, it would be hard. This
region, Nimba, would likely be one of the first hit as we receive
quite a bit of trade traffic from Guinea and even Ivory Coast. If
contaminated birds would be confirmed here, the government would
likely mandate incineration of all poultry in the county, which would
then mean a probable shortage of food.

I should certainly add that that's a worst-case scenario, but at the
same time we are trying to stay as prepared as possible.

So, the incident on the radio, it turns out, was most likely food
poisoning. This happens from time to time around here, I guess. No
bird flu for us. Yay.

...

Me:"W, does this part of town have a name?"
W:"[yes]. I used to live here. I had a house, you can just see it
there. (points). Down the hillside, there."
Me:"You moved?"
W:"This part of town, during the third war, was no-man's land. From
there (points) to the bridge, you could not walk, you could not go. No
man's land. The governement had snipers on those two buildings there.
The rebels was across the bridge. Anyone going across, pop, they shoot
you, you die there on the bridge. Pop, pop."
Me:"so you moved, it was too close to no man's land?"
W:"No, no, that was ok. Just don't go into no-man's land!" *laughs*
"No, one day, the well there (points), it dries up. You need the well,
you need the water! Can't live there no water. So we cleaned it up. It
was dirty. We cleaned it up, when we clean, we find seven human
skulls. Seven skulls. Seven human skulls in the well. That night, I
can't sleep, I'm crying all night, no sleep. All I think about is
those seven people, skulls in the well, crying. I can't live there
anymore, near that well."

Ready to go...again...

Well, my two weeks are up tomorrow, and I'm finally heading back to my
project, team, and the reason I'm here in the first place.
Sure, the training has been interesting, in a sort of geeky way, but
all the same, I didn't come all the way to Liberia to sit in a room
for 12 hours a day for two weeks and learn about a database that I
won't really be using anyway.

I actually feel quite comfortable at this point in Monrovia...for all
its differences from, well, anywhere else in the world I've been to.
I'm actually fairly surprised at how well I seem to be adjusting, in
general, and specifically to being in Monrovia and Sanniquellie. I
expected to have a much harder time. I got to go to the Waterside
market again today (had to pick up some jerseys for Jens and trainers
for me), and I definitely like it - it feels like 'life'...as opposed
to being in the compound, which feels pretty isolated and separate
from the world around.

Aside from the training, life in Monrovia's pretty easy. If it's any
indication, all the expats who work here have very nicely refined
tans. None of the expats in the field have such a thing. When I've not
been in the training, I've been sitting on the terrace watching the
Atlantic, watching kids play soccer on the beach (note: from here on
out, since everybody else does it, I'll be referring to soccer as
"football", the way it should be), having a beer, chatting with the
head of mission(s), maybe going to the beach, and generally not having
too stressful a time.

By contrast, I understand that during my absence in Sanniquellie, the
compound has no water, a broken submersible pump, no power if the
generator isn't running, no refrigeration, and the fence has been
blown down. Oh, and the hospital also has no water, two broken wells,
and, well...the list goes on.

All of which makes me, actually, VERY excited to get back up to
Sanniquellie and get to work! I'm definitely ready to feel like I'm
doing what I came here for.

Gotta go, just got some interesting news and need to follow it up.
I'll let you know what happens.
ciao
taj

Yesterday, it rained in Monrovia.

There must be no sound in the world like that of a tropical deluge
falling simultaneously on hundreds of thousands of tin roofs, across a
city of millions.

Monrovia's usually very loud...during the day, evening, even at night.
It's a regular cacophony of people talking, horns honking, sirens
blaring, arguments, and a constant crash in the background of the
surf. But when the rain falls, it simply drowns out all else. The
drumming is deafening at times...It's really quite something.

I'm looking forward (with trepidation) to the first rains in
Sanniquellie. It will be a markedly different experience. There are
nowhere near so many people there, and Sangba base is fairly outside
the town itself. As such I expect it to be a much different
environment when the rain falls. I understand from my project team
that it has been raining the last week (and here I am in Monrovia...).
Everything's absolutely soaked. Ah, well. The rainy season "begins" in
late April, and then I'll have a solid 6 months of my own to
experience it. Over and over and over.

It's Sunday and I'm in Monrovia. This can only mean one thing: I'm off
to the beach.

ciao for now.
taj

A rough weekend

The time in Monrovia is a lot different from time in Sanniquellie, but
the weekend was really nice. On Saturday, we visited an IDP camp -
Internally Displaced Persons camp - that's up on the central hill in
the city. IDP's are like domestic refugees - they don't get refugee
status because they haven't left their home country but they have fled
their home place and have nothing in wherever they are.

So, anyway, the government of Liberia has set up an IDP camp in the
middle of Monrovia. How, you ask? Well, there was an abandoned 9-story
luxury hotel that was never quite finished before the third war.
Because it was in a central, strategic location during the war, it was
the subject of intense fighting for control. Now, however, it's all
beat up to hell.
So the government has decided to put some 4500 IDPs in the hotel.

It's quite a sight. Of course there's no power, no water, no toilets
in this hotel. In some ways, I think it's a worse locale for IDP
housing than a sprawling camp in a desert or something. The squalor is
quite tremendous, just what you'd expect from 4500 people living in a
building that has no utilities whatsoever. But at the same time,
people have obviously adapted to the conditions. Because of the
density of the population in the building, enterprising refugees have
set up small shops in the (dark) hallways and sell bits of food or
water. At the light end of one hallway, a woman has established a
hair-styling business. Well, it's a stool and a mat on the floor, but
it's a business.
On the first floor, another NGO has turned a couple parts of the lobby
into school rooms. They don't have benches, books, or school supplies,
but they have a chalk board and some people who teach. When I went to
the hotel, there were a kindergarten, 1st, and 2nd grade class all in
session. And of course they were about as excited to see two white men
as all Liberian children are - and that's REALLY happy. Bouncing,
laughing, talking, smiling.
"The Hotel" is a bit of a tourist destination for expats visiting or
passing through Monrovia. That in and of itself makes for quite the
strange sensation - everyone says you need to see this place, but to
actually go and walk through and maybe get a tour or talk with people
makes you feel tremendously rude and out of place. It was the worst
sensation to meet a group of expats from Mercy Ships coming out as we
were going in and another group of expats from MDM coming in as we
were going out. It felt a bit like somehow the nature of this place
had become an attraction - a distinctly perverse attraction. After
all, who would _want_ to go visit a building where for four years
thousands of people who were forced out of their homes by war, death,
rape, and poverty have been living, without any access to basic
services or amenities?
All the same, it does bring another type of gravity to the situation
here. Things are improving, but obviously it takes time.

After visiting the hotel Jens and I went to the Waterside market.
Waterside is where Monrovians go to buy things. It's a tremendously
dense section of Monrovia with hundreds and hundreds of stalls, sort
of loosely arranged by type of goods for sale. For instance, Jens and
I didn't spend much time in the 'curtains' section, but lots of time
in the football (soccer) paraphenalia section. Of course, there's
quite a bit of intermingling.
But to the point - it is a distinctly good way to get a feel for the
city. It's full of people hawking all sorts of wares. It's crowded,
smelly, there's piles of trash and refuse littering the street, and
you definitely have to watch where you walk. But it's full of the
people and atmospherically filled with their spirit. For the first
time since I arrived I finally got a bit of a feel for Liberia, I
think. The way they walk or talk together, argue, buy stuff - just
really a feel for everyday life for people who live here. I've spent
so much time in the various compounds in Sanniquellie and Monrovia
that I hadn't yet gotten at all a sense for that before. But I really
do feel like maybe I have a better sense of 'normal' for someone who
lives here. I think that's important.

Then, at the reverse side of things, I went out to dinner and brunch.
I arrived early in Monrovia because another expat (Jens, from Germany)
needed to take a weekend break in the capital - to get away for a
weekend. Since he was going down anyway, to conserve resources and
such, we decided to just have me go along as well. So we came in on
Friday evening. In any case, as part of his 'relaxing weekend' he very
reasonably wanted to do relaxing things. We had a very nice dinner
with Yuri and Sebastian nearby the compound on Saturday evening, with
real western style food in an african restaurant. That was OK. Then
Saturday night we attended a going-away party for the Head of Mission
for MSF-Belgium (just down the street from us here) where all sections
were invited and national staff attended.

Sunday we got up and went to brunch at the Royal Hotel. That was a bit
too much. I could have been sitting in the dining room at a Holiday
Inn. Air conditioned, with a full spread of totally western food, and
attending were only expats. No africa-africans to be seen. The food
was good, but really it was an unsettling feeling.

After that we went to the beach, where, well, if you read the previous
post, you have a good idea what happened. But it was nice to sit and
relax and read a book and listen to the surf and watch the waves and
such. And, honestly, until I got back to base I thought I was OK -
even Jens said he was surprised "When we left the beach you were still
white as a ghost! Now you're really, reallly red!"

I get along great with Jens - he's a really cool guy; very relaxed and
down-to-earth. He's an anesthesiologist. Unfortunatley, he's leaving
in April. Ah, well. It'll be fun while it lasts. He and I definitely
have a good time together.

Then in the evening we started the workshop on the new software,
which, well, I'm still not too keen on, but I have to do it.
Today was more software, and every day from here until the 15th. It'll
be fine in the end, I have no doubts.
Now I'm to bed. Sleep well.
taj

Imagine, if you will...

A splendid beefsteak tomato. Picture it hanging on the vine, in the
middle of summer. It has been waiting for months to be ripe, and has
fully matured over the last weeks. It has been basking in the sun of
hot summer for months. The skin, shimmering and deep in its redness,
has finally reached a superlative crimson tone.

This, approximately, is the color of my skin after a day at the beach.

Despite my best intentions, despite three coats of SPF30 sunblock and
spending most of the day (6 of 8 hours) in the shade of the papol hut,
I have managed to emerge from the day a brilliant - some might say
blinding - garnet lustre.

*sigh*

Back in Monrovia

After only two weeks in Sanniquellie, I find myself once again in
Monrovia, this time for a training for new logistics software that's
supposed to make my life easier. We'll see...

But, I'm once again in the big city...with everything that entails.
I'll be here for two weeks straight.

Even just two weeks in Sanniquellie, the shift back to Monrovia is
surprisingly jarring. Compared to Sanniquellie (well, probably
compared to anywhere else), Monrovia is sprawling, hot, crowded, and
noisy. But hopefuly I'll have a good time.

Off to an IDP camp...more as I get a chance.

ciao

A few thoughts on: Food.

I've only been here two weeks. As such, I feel compelled to be honest
and state that my perspective on this matter may very well change over
the next 8.5 months.

But, suffice to say, for now: the food is great!

Granted, we've been very lucky these last two weeks that we've had
lots of food brought up on kiss movements from Monrovia (a kiss
movement is where one car leaves each location, in this case Monrovia
and Sanniquellie, and meet in the middle, exchange cargoes, and head
back to home). As a result, we've had a lot of chicken, cheese,
olives, even some chocolates and the like.

Our project is (relatively) unique in that for some reason they've
decided to have the cook on duty 7 days a week. Most projects
apparently have the cook only 5.5 days per week, leaving Saturday
nights and Sundays up for grabs as to what happens. But we've got a
cook here all day, every day.

I could get used to this :)

Breakfast is at one's leisure, nothing is prepared. The team keeps a
stock of corn flakes, powdered milk (Nido), honey, sometimes bread
(not very good I must admit), peanut butter, sometimes it has
preserves, and instant coffee. I'm not much of a breakfast person, but
I am trying to make sure I get three meals a day, so I've started
eating cornflakes and powdered milk. It's not that bad!

Lunch is prepared by the cook(s): Rebecca on M-Th, Kou on F-Su.
There's always protein, usually one animal and one vegetable (we've
got vegetarians), and at least one type of starch, typically rice.
(Meat) Proteins vary from dried fish, fresh fish, beef (uncommon),
goat, and chicken if we have it brought up from Monrovia. Vegetable
proteins are usually lentils, and so far I've had at least three
different colors. We had canned pork & beans once. Right now we're
smack dab in the middle of pineapple season, and damn they're fine. I
think I could eat ripe pineapple all day every day. Sometime in June
mango season starts and I'm excited about that!
Vegetables are in relatively short supply here, so we don't get much.
I'm compensating by eating heaps of pineapple. Yesterday we had a
papaya, but it wasn't fully ripe yet. Coconuts grow out back (behind
the latrines...).

Dinner is whatever is left over from lunch, plus another round of
something cooked. Same kind of things, but two proteins and two
starches or three. Leftovers go to the guards.

So...style of food? The only thing I can come up with is west african.
I certainly recognize that my exposure to African food is apparently
quite small. Like most food from tropical climates, it's heavily
seasoned to mask, of course, the flavor of things gone bad. They make
liberal use of hot peppers (yay!). Spices themselves? I've recognized
cumin, coriander, tumeric...maybe nutmeg. I'm still working on that
one. Lots of saucy/curry type dishes (but no curry). At some point
I'll start asking what things are.

People who sell things on the side of the road may have grilled kabob
type things (i've not been here long enough to risk trying one), they
also have bags of kool-aid type beverages (again, not brave enough
yet), and, well, other things. I've not been out of the compound that
much, honestly.

There's more, but there are nine of us here and a queue forming for
the one internet computer. My time is up.

Ciao
taj