Comings and goings...

So when I signed up I was given the impression I might be alone on the ground in Monrovia. That didn't change until about 3 days before I left when I finally got an email saying not only would I be picked up at the airport, but that a bunch of people would be here. That being said, over this past week they've all left. Thanks to Louis from UofChic ED, jonathan from UofChic IM, Tammie and Tricia from UMass Peds, and Marcia from Tulane IM (this crazy chick has been in Liberia since January! Either committed or should be...).

The rumor is that one of this past year's first HEARTT Residents will be coming back a few days before I leave in July. Hope that's true. So much of this kind of stuff is "medical tourism," without even a continuing presence, let alone a self-conscious effort to emphasize development work. Hope hope hope. Hope for something good to come of your time, the breaths you take. Hope for people to be better than they expected to be. Hope some things matter, after all. We'll see.

But thanks to my new friends. "May we always remember the people we have been; may we ever be ready to meet again for the first time."

We are living in a Liberian world, and I am a Liberian girl, er, I mean, boy...

Sorry it's been a while since posting-- there's more and more kinds of work here than I anticipated...

So, where are you again? Liberia, West Africa. Oh. So, where are you again? Well, read on. I've tried to put it into sections, as well as a section specifically on JFK Hospital, where I am now, and a few key numbers after that. A lot of the below information comes from the 2006 and 2008 UN Country information, but from what I can tell, not much has changed...
Oh, and some media on Liberia: movies- Liberia: America's Stepchild, Sliding Liberia (we met Alfred, who's featured in the movie) books- Through the Liberia Storm and Liberia: the Path to War (both written by a Nigerian MD who's here with us now), also Blue Clay People, and This Child will be blessed (I think, the autobiography of Liberia's president, Ellen Johnson Sirleaf, who is the first female head of state in Africa)

COUNTRY OVERVIEW

Liberia is situated in West Africa, bordering the Gulf of Guinea, Côte d'Ivoire, Guinea and Sierra Leone. Lying just north of the equator, the country has a tropical climate and is one of the wettest in the world, with an average annual rainfall of more than 5,000 mm in Monrovia. Liberia’s population is currently estimated at 3.4 million with an annual growth rate of 4.9 percent.1 Average life expectancy is 39 years2 and an estimated 50 per cent of the population are below the age of 203. 95 per cent of Liberians belong to one of 16 indigenous tribes.4 The

remaining population consists of Americo-Liberians and so-called Congo people, descendants of immigrants from the United States and Caribbean. An estimated 40 per cent of the population hold indigenous beliefs, 40 per

cent are Christian and 20 per cent Muslim. 5 Liberia is rich in natural resources, including iron ore, timber, diamonds, gold and potential for hydropower. Despite this natural wealth, it is among the poorest countries in the world measured in terms of per capita income. Liberia is not currently rated on the Human Development Index (HDI) given the lack of data. However, its HDI rating in 1999 was 0.276, down from 0.311 in 1996, placing it second from the bottom on the list of countries.6 The economy of Liberia reflects the toll of the war. Per capita GDP stands at US$ 163, a dramatic drop from the 1980 level of US$ 1,269. Foreign debt exceeds US$ 3.7 billion (650 per cent of GDP). Unemployment is estimated at 85 per cent, with nearly half the population existing on less than US$ 0.50 per day. Some 86 per cent of the poor live in rural areas7. Liberia’s economy is dominated by agriculture, which accounted for 52 per cent of GDP in 20058 - or a commanding 77 per cent including forestry.9 Only 12 per cent of GDP is generated from the industrial sector.

1 CIA World Fact Book, June 2006

2 37 year for males and 41 years for females

3 UN Liberia Human Development Report DRAFT 2006

4 Kpelle, Bassa, Gio, Kru, Grebo, Mano, Krahn, Gola,

Gbandi, Loma, Kissi, Vai, Dei, Bella, Mandingo and Mende

5 CIA, June 2006

6 MDGR, 2004

7 ibid.

8 IMF 2006

9 CIA, June 2006

ECONOMICS

With the end of the war and restoration of security, the economy has begun to improve; increased activity in urban areas has contributed to an estimated GDP growth rate of 5.3 per cent in 2005, double that of the preceding year. However, current growth is neither equitable nor based on sound management of national

resources. Issues of sustainability will emerge unless conditions become conducive to private investment and public expenditure is directed towards reconstruction and job-creation.

Food security requires that ‘all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.’17 For the vast majority of Liberians, this is not the situation today. At least 810,000 are receiving food assistance through

resettlement, school feeding, food for work and institutional feeding programmes. The agricultural sector is fundamental in an economy based on natural resources. Liberia’s conflict largely destroyed an agricultural sector

already weakened by previous government policies subsidizing food imports at the expense of local producers. Widespread displacement of the population also adversely impacted agricultural production and the food security

situation. Today, approximately 95 per cent of urban food needs have to be met through imports, including rice and other staples.

HEALTH:

Conflict led to the forced movement of health workers and professionals into IDP camps and as refugees to neighbouring countries. Health facilities were looted and vandalized and medical supplies became

unavailable. As most parts of the country were inaccessible and national security was given the highest priority by the government, funding stopped and health services collapsed. The problem of skilled health staff cannot be

overemphasized. Liberia today has only 26 medical doctors in clinical practice. Insufficient skilled personnel, poor referral systems and inadequate health facilities are of great concern as are the lack of essential drugs and supplies, including reproductive health (RH) commodities. The decline in health services came with increased health problems arising from the conflict, including hunger, disease and the spread of HIV/AIDS. As levels of poverty and hunger rose, many young girls resorted to prostitution as a means of survival. This led to a range of health problems including sexually transmitted infections. Regional conflict, and the movement of fighters across borders, coupled with the use of sexual violence as a strategy of combat, further exacerbated the HIV/AIDS situation. The vast majority of Liberia’s public health care continues to be externally supported. The

national budget for health has in real terms declined considerably since 1990 and resources committed to the sector are insufficient to provide a basic level and quality of service.

Priority health issues: Within the range of health problems facing Liberia the United Nations identifies the following priority areas:

1. Maternal Health: Despite an absence of reliable data on the current maternal health situation, figures from the 1999/2000 Demographic and Health Survey showed Liberia to have one of the highest maternal mortality

rates (MMR) in the world, estimated at 578 per 100,000 live births – more than twice the 1986 estimate of 260.23

Access to maternal health care services, especially basic and comprehensive emergency obstetric, antenatal, and postnatal care and RH services including family planning, and information and counselling remain grossly

inadequate - especially in rural areas. The Liberia Safe Motherhood Needs Assessment puts institutional deliveries at 11 per cent. The referral system is close to non-existent. Unwanted pregnancies resulting in complications and unsafe abortions are common. Maternal nutrition is also poor. All of these are responsible for high maternal mortality and it is highly unlikely that Liberia will meet related MDG targets by 2015

given the current conditions.

2. Child Mortality and Health: Data on newborn morbidity and mortality are not available and programmes for newborn care are lacking. Available data indicate that infant mortality rates remain high, estimated at 157 per 1,000 live births.24 Liberia is unlikely to meet the MDG target to reduce child mortality.

3. Malaria: Malaria accounts for up to 10 per cent of all deaths in Liberia. Malaria cases increased from 35 per cent of clinic visitors in 1997 to 50 per cent in 2000. Strategies for controlling malaria prior to the conflict mainly involved prevention through bed-netting and insecticide application, with a limited amount of

prophylaxis distributed for pregnant women. New strategies are required and much work remains if Liberia is to meet the target of halting and beginning to reverse the incidence of malaria by 2015.25

4. HIV/AIDS: National prevalence of HIV/AIDS in Liberia is not known but some estimates put the infection rate as having doubled from 4.2 per cent in 1994 to 8.2 per cent in 2001.26 Prevalence rates among women are higher than men, with the infection rate among pregnant women aged 15 to 24 rising from 4.2 per cent in

1994 to 12.9 per cent in 200027. Though antiretroviral (ARV) treatment guidelines have been designed under the Global Fund Programme, healthcare providers lack the necessary expertise and apparatus for managing HIV/AIDS cases. Prevention of HIV/AIDS requires the joint effort of the entire society and is therefore discussed at greater length as a cross-cutting imperative.

5. Nutrition: Nutritional status deteriorated significantly as a result of the years of conflict in Liberia. In 2002, 46 per cent of the population were estimated to be undernourished.28 Malnutrition is pervasive among children under five years of age. Children also suffer from anaemia and vitamin A deficiency. Micronutrient deficiencies were also prevalent, with 86 per cent of children aged 6-23 months anaemic and 53 per cent deficient in vitamin A - exacerbating the condition of those suffering from malaria, diarrhoea and acute respiratory infections.

Numerous other diseases also affect Liberia’s population. It is estimated that 29 per cent of children 0 to 59 months of age suffer from acute respiratory infections such as pneumonia. Diarrhoea accounted for up to five percent of inpatient and out-patient consultations in 2004.29 Tuberculosis rates are estimated at four per

1,000. Certain diseases such as schistsosomiasis impose huge costs on the agricultural economy.

Mental health problems are prevalent and there are no programmes to adequately address adolescent health issues.

John F. Kennedy Medical Center:

JFK Medical Center, located in the central Sinkor District of Monrovia, is the academic teaching hospital of Liberia and is affiliated with the University of Liberia A.M. Dogliotti College of Medicine. From 1989-2003, Liberia suffered from continuous armed conflict. Prior to that period, the hospital served as the center for clinical training for adult, pediatric, surgical, nursing, and allied health services. However, the conflict greatly damaged JFK Medical Center’s capacity to provide care and training, and even led to the hospital’s periodic closure. Fortunately, with a return to peace, and thanks to the commitment of its staff and leadership, JFK Medical Center is rebuilding. Efforts are under way throughout the hospital to restore its previous health services and resident training programs.

ECONOMIC INDICATORS

GDP at current market prices (US$ million) (2005) 574.5

GDP at 1992 constant prices (US$ million) (2006) 433.2

Unemployment rate (%) 80

Private sector employment (2006) 74,774

Public sector employment (2006) 58,500

Informal sector employment (2006) 470,000

GDP per capita (in 2005 US$ prices) 163

GDP growth rate (2006 estimate %) 7.8

Inflation rate (est average 2006 %) 4

External debt (US$ billion) 3.7

Domestic debt (US$ million) 700

National budget 2006/07 (US$ million) 129.9

Average lending rate (%) 16.4

Net remittances (inflow minus transfers of money, US$ million) 54.2

Imports (US$ million) 443.8

Exports (US$ million) 180.8

Total trade value (US$ million) 624.6

Trade deficit (net trade value, US$ million) 263

SOCIO-DEMOGRAPHIC INDICATORS

Population size (projection in millions) 3.6

Population growth rate (%) 4.6

Life expectancy at birth (years) 47.7

Illiteracy rate (%) 70

Infant mortality rate (per 1,000 live births) 157

Under five mortality rate (per 1,000 live births) 235

Maternal mortality rate (per 100,000 live births) 578

% population below poverty line (living on less than US$1 per day) 76.2

HIV/AIDS prevalence rate (%) 5.2

Human Development Index 0.319

Total geographic area (km sq) 111,370

Total land area (km sq) 96,320

Coastline (km) 579

POLITICAL INDICATORS

Government Republican

Presidency Executive

Legislature Bi-cameral

Senators (30)

Male 25

Female 5

Representatives (64)

Male 56

Female 8

Executive (Cabinet Ministers)

Male 15

Female 5

Proposed size of the National Army of Liberia (AFL) 2,000

Proposed size of the National Police and security forces 6,000

Sources:

1. Human Development Report 2006/Interim Poverty Reduction Strategy Paper (iPRSP)

2. Second Review of Performance under the Staff-Monitored Programme, IMF

3. LISGIS, Liberia National Population Panel 2007

(Population estimate of 3.6 matches with the target developed by NEC for local elections in 2007).

4. Bureau of the Budget/Ministry of Finance

5. The President’s 2006 Annual Message, 29 January 2007

6. Annual Report 2006, Central Bank of Liberia

7. WHO Report 2006

6

Getting there is half the fun

Hi there,
Made the trip from JFK to Brussels on American Airlines, where an Italian drummer and I compared (unfavorably) US to European and South American airlines. I wagered the plane would be roomier from Brussels to Monrovia, and a few hours later, I was right. Travel tip: 100 ml is the max size for carry-on liquids in Brussels. So I was deprived of my shaving cream, sunblock and, most distressingly, 30% DEET bug spray.

No matter, soldiered on, found out via email I owe New York taxes for 2008, and arrived at Roberts Intnl airport without a problem. One of the hospital drivers met me there and after 45 min on the road, made it to JFK Hospital! More to follow, though the electricity and internet are touch and go...

"You are a traveler at heart; there will be many journeys"

The title comes from a fortune I got from a Kenyon College AMARK food services fortune cookie and have kept with me since. I like it. Below is a poem introduced to me by an old friend. I think it speaks to anyone who's thought deeply about travel and work in the "developing world."

Questions of Travel -- Elizabeth Bishop

There are too many waterfalls here;
the crowded streams
hurry too rapidly down to the sea,
and the pressure of so many clouds
on the mountaintops
makes them spill over the sides
in soft slow-motion,
turning to waterfalls under our very eyes.
--For if those streaks, those mile-long, shiny,
tearstains, aren't waterfalls yet,
in a quick age or so, as ages go here,
they probably will be.
But if the streams and clouds keep travelling, travelling,
the mountains look like the hulls of capsized ships,
slime-hung and barnacled.

Think of the long trip home.
Should we have stayed at home and thought of here?
Where should we be today?
Is it right to be watching strangers in a play
in this strangest of theatres?
What childishness is it that while there's a breath of life
in our bodies, we are determined to rush
to see the sun the other way around?
The tiniest green hummingbird in the world?
To stare at some inexplicable old stonework,
inexplicable and impenetrable,
at any view,
instantly seen and always, always delightful?
Oh, must we dream our dreams
and have them, too?
And have we room
for one more folded sunset, still quite warm?

But surely it would have been a pity
not to have seen the trees along this road,
really exaggerated in their beauty,
not to have seen them gesturing
like noble pantomimists, robed in pink.
--Not to have had to stop for gas and heard
the sad, two-noted, wooden tune
of disparate wooden clogs
carelessly clacking over
a grease-stained filling-station floor.
(In another country the clogs would all be tested.
Each pair there would have identical pitch.)
--A pity not to have heard
the other, less primitive music of the fat brown bird
who sings above the broken gasoline pump
in a bamboo church of Jesuit baroque:
three towers, five silver crosses.
--Yes, a pity not to have pondered,
blurr'dly and inconclusively,
on what connection can exist for centuries
between the crudest wooden footwear
and, careful and finicky,
the whittled fantasies of wooden footwear
and, careful and finicky,
the whittled fantasies of wooden cages.
--Never to have studied history in
the weak calligraphy of songbirds' cages.
--And never to have had to listen to rain
so much like politicians' speeches:
two hours of unrelenting oratory
and then a sudden golden silence
in which the traveller takes a notebook, writes:

"Is it lack of imagination that makes us come
to imagined places, not just stay at home?
Or could Pascal have been not entirely right
about just sitting quietly in one's room?

Continent, city, country, society:
the choice is never wide and never free.
And here, or there . . . No. Should we have stayed at home,
wherever that may be?"