The Hospital On The Hill

Built into the hillside, just bellow the mountain spring that supplies drinking water, and  adjacent to the Episcopal Mission High School, St Timothy Hospital overlooks the town of Robersport. It is visible all the way from the beach, a white washed, concrete structure with blue lettering bearing the name of the original mission site and shuttered windows all in a line, like square portholes, also painted blue.

The nurses’ dormitory stands to the left. I am told that before the wars, this hospital was a primary site for nursing apprenticeship education. However, it was also always acknowledged to be "a hardship post", due to its remoteness and arguable degree of isolation. While perhaps not the most desirable location for those hoping to rub shoulders in Monrovia, Liberian nurses have a long history of coming to Grand Cape Mount, and to St. Timothy, to train.

Today, the dorms are not as full as they could be, should be, nor is the hospital. Staffing is limited, resources are scant, and utilization of services not maximized, creating a chicken before the egg conundrum. On one hand, to bolster the archaic technology and greatly expand staffing in the hospital and provide up to date, comprehensive services to patients, or the other, do we need first to be overwhelmed by patients, to justify this investment? The daily reality is a bad case of in between. Still, the core team of hospital workers shows up, day in and day out, to provide care to Cape Mountinians, regardless of the fact that they have not been paid for 3 months.

Our first day at St. Timothy was marked by an introduction meeting. We were presented to the staff by Dr. Garlo, the only doctor at this estimated 50 bed hospital. Dr. Garlo is one of the few remaining fully trained Liberian doctors. Estimates by various NGO groups vary, but there is agreement that there are less than 100 Liberian doctors in the entire country. That is about 1 doctor per every 135,000 people.

Keep in mind the cycles of mass exodus from this region over a 20 year period of conflict. The majority of direct clinical care and maintenance of the health infrastructure is still provided by external sources-the UN, missionaries, and NGO groups. While there are Liberians, and other West Africans employed by these groups, the majority are expatriate staff from “the western world”.  Of note, the China is investing hugely in Liberia, paving roads, building schools, health clinics, and providing the one and only CT scan machine in the entire country. All this in exchange for fishing rights to Liberia’s coast line, land to clear cut for production of palm oil, and other crops. Many dynamics and implications here, but I’ll save it for another time.

When Dr. Garlo was appointed by the Ministry Of Health to St. Timothy, there had been no doctor in residence for over a year. He is responsible for the hospital, all the health clinics of Grand Cape Mount County, and for county wide health care administration. Like most of the clinical staff at Cape Mount, he boards at the hospital, and commutes to visit his family when possible. Along side Dr. Garlo is Mr. Quaye, or “Pa” Quaye, a Physicians Assistant who remained in Robertsport during the war when the entire community was sealed off from the rest of the country by rebel warlords. He was one of the few health care providers during that time of terror.

We waited in the courtyard of the hospital that first morning, along side serious faced staff members. They seemed unsure of us, or of our presence within their daily routine. We stood, scrub clad, with our pocket guides to tropical medicine, World Health Organization guidelines, and regional essential guides for drug treatment regimes, still sweating profusely from the climb up the hill. We had taken the foot path, a root tangled, dirt trail that is preferable because it is shaded by palms, instead of the winding, dusty road that requires 4WD low to make the ascent. Now, as the sweat ran and cooled down our backs, we were able to stare out at the green tree tops below, the strip of beach lacing the town's edge, and a never ending blue ocean, with tufting white caps breaking gently, far off shore.

Nurse Ahmi arrived, in pressed white, caring her signature ring of keys. A round woman with lovely, ink black eyes, and neat rows of braids pinned at the base of her short neck. She eyed us with contemplation and addressed her crew, "All my soldiers are still standing...the day is good". They seemed relaxed by her presence, and nodded, "Yah ma'am.", shaking hands all around.

When Dr. Garlo arrived, he led us all into the conference office, an airy room filled with sunlight and a large, rough wood table, surrounded by white plastic chairs in neat rows. The staff dutifully sat as we were presented. Our introductions were formal. When encouraged to speak, we tried to convey warmness, intentions for partnership, and optimism. My guess was the first impression made was...not the worst? I sensed "watch and wait" all around, and internally responded, "fair enough".

Relatively soon, the days began to take on a familiar enough routine. Arrival at the hospital as the early heat of the day begins. The concrete floors are being swept and mopped, the patients’ families shuffle in and out with basins of water, plastic buckets of every color, often balanced upon heads, to wash. Women wrapped in brightly printed lappa cloth, carry bars of soap, hair combs, and clean laundry off the outside clothes line. They wait in line to refill water buckets, fresh from their own bucket shower, with powder dotting collarbone lines, a dusky white contrast against deep black skin. Infants with skin and hair freshly oiled bounce on sagging mattresses, waving spoons into cups of rice water, gumming their hospital issued, sesame-seed covered breakfast  “biscuit”. Malaria nets tied neatly above the cots flutter now and then, like ghosts from the night passed.

Rounds occur at each patient’s bedside. Pa Quaye, inspects the infants, then adults, flanked by the nurses who hold each chart, and scramble to rattle off vital signs when and if asked. Most assessments focus on things like “The baby sucking?” As in, is the child breastfeeding, or “This boy, he can drink?” to see if a child is able to keep fluids down. Meanwhile, patients waiting for the outpatient department line benches and vaguely engage in the daily education message, recited by a nurse tasked with addressing “ways that we prevent sexually transmitted infections”, or, “tell the real thing, so!…how we get this thing, TB”.

Rounds and treatment of outpatient illness are as much about discussing drugs to prescribe based on what is actually available as they are about care planning and case management. Quinine, first line of treatment for Malaria in Liberia, is on the order sheet for about 70% of the inpatients, despite their original presenting symptoms. However, it is a rare day that the hospital pharmacy has enough to dose all patients as ordered. Typically, once patients finish their 3 day IV course and need to be transitioned to tablets for 4 days to complete treatment, we ask their family to walk down the hill, go to the pharmacy in town to buy the medication.

Underlying, chronic pathologies such as anemia or malnutrition are addressed with pleas to care givers such as “mix some greens into this child’s fu fu, eh? He need it to make his blood strong.  Blood be TOO low after Malaria, get the greens!” to which the mothers nod dutifully.

After rounds, depending on whether there are 1 or 2 nurses assigned to all 26 inpatients, I either commence with the passing of meds, mostly in the pediatrics ward, which comprises most of the inpatient population, or work in the free standing clinic that sees all the patients under 5 years old. From here, children are evaluated for their current complaint (usually fever, gastrointestinal illness, skin infections or abscesses, cough or rapid breathing).

If they meet criteria for admission, I send them across the courtyard to the pediatric ward with a yellow card to present to the nurse. I write the focused history, physical exam findings, admission orders for drugs and fluids, based on standardized guidelines for management of symptoms based on Integrated Management of Childhood and Neonatal Illness (IMNCI) protocols. This set of treatment protocols are designed for use at the community clinic level. Clinic staff are trained to follow step by step assessment questions, and make basic clinical observations to recognize danger signs for severe disease such as dangerously high respiratory rates, chest indrawing, fever measured beyond a certain point, convulsions, signs for severe dehydration.

I myself can’t help but couple these guidelines with a differential based on health history and physical exam. I write the protocol orders, then call the on call MD or PA if I want to alter or modify the orders to prevent what I worry might be excessive use of antibiotics. Still, I am learning how quickly these children get sick, very sick. I understand why we treat a fever, or refusal to breastfeed for a day, so aggressively.

The non-admits receive treatment, a prescription to take to the pharmacy. If their reason for coming is more of a return, follow up visit, we weigh the children, plot their growth on their Road to Health Cards, and usually I counsel them to promote nutrition and other behaviors for good health.We discuss hand washing and hygiene (rub your hands fast while someone pours from the water scoop for you, dipping hands into the bucket does not wash away the dirt, cover your water basins, treat your latrines, don’t allow people to pee pee or poo poo in the yards, make them go off to the side).

I make a big production about "the power" of green leafy vegetables, and foods with color (mango-called plum, avocado-called butter pear) and how to crush them, mix into the rice porridge. We discuss that children are like chickens, that they need to eat frequent, small meals, 5 or more times a day, not one big plate of rice, set on the floor, in the dark of the morning or dusk of night. We discuss that it takes time to feed children, that you actually have to put the food to their months, feed them “actively”…that otherwise they will not take in as much food, as many calories, or complementary foods.

We discuss breastfeeding, how it is a thing that even a poor mother can give to her child, valuable for good health, more than any money. We discuss and practice making homemade rehydration solutions-boil the water, cool it, let the child sip it, from a clean cup or spoon. If the child likes, add a little coconut water. We review the vaccine schedules, and I spend a lot of time listening to the practices of “country medicine”, and other traditional treatments and practices. Most infants have tiny metal bracelets, bands of thread, little woven string basket charms, or other emblems for protection knotted around their waists, beneath their diaper cloths, or around their necks.

I look at these young, thin, sweating and worn mothers, who offer their backs and breasts to carry and comfort their infants. I wonder, as I often do at home, at the disconnect between what I am asking that people add or change about their daily routine, the benefits that these things could bring, and what is realistic for them to consider. I know that many of these mothers have been up since before light, to haul wood and water, to prepare food, to smoke and then sell fish, to walk 5 or more kilometers to come to their clinic visit, have climbed the hill, carrying 1 or 2 children, and are now sweltering on a wooden bench, fanning themselves. I know that some have “a touch” of Malaria themselves, are anemic, that they likely eat last from the family pot, once a day.

By 3 o’clock, a calm settles over the hospital campus. Peak temperature for the day has set in, and the sun reflects off the tin roof. The glare reflects off the large rocks the line and holds together the dirt road. Funny shadows are cast across the cement courtyard where brightly colored laundry drip dries from clothes lines that zig zag between the support pillars.Socks, children’s diaper covers, and t-shirts bearing the logo and names of American Little League teams, Turkey Trot 5k fundraisers, and other clothes items that make their way across the Atlantic to African clothes markets fill the space between squares of lappa cloth. This cloth, patterned cotton prints in bright, often geometric shapes, is worn as skirts and head wraps, used as blankets for newborns, as diapers for infants, to wipe noses and children’s faces, to lift away hot pot lids, and to cover the mattresses of the archaic hospital beds inside.

At this point, morning medications have been “served” by the nurses, and new admissions have been received from the outpatient clinics or ER.  New IV lines have been placed, the corresponding wailing  has ceased. The pharmacy has dispensed small zip lock bags of pills through their grated window, with slash marks made care fully to indicate taking the tablets 1-1, as in one in the morning, one at night, or 1-1-1-, morning, noon and night. The closet room used as a laboratory, where malria smears are interpreted and blood samples are spun down to be measure hemoglobin levels, is now locked and closed. If a new patient arrives, through the emergency area or otherwise, the nursing staff will have to call the lab tech on his cell phone and hope that he will come before rounds the next morning. The clinic's bleacher style benches are now empty, save for the stray person that has chosen to stay and sleep in the shade of the covered hallways. 

The adult inpatients hitch up their hospital gowns, maybe put on a t-shirt over top, and wheel their IV poles or carry their urinary catheter bags in order to go stroll outside. They sit on benches or the front cement steps, trying to feel some breeze or movement of air. They gossip and watch foot traffic on the road below. Sometimes they comment on the state of the ocean, further on, towards the horizon. If there are visible white caps, or the sky begins to darken with an impending storm, they might remark, “the sea, its troubled today”.
 
Inside, on the pediatric ward, the infants sleep while their IV medications infuse; yellow colored potions roll from the drip chambers, down the tubing, bringing “science medicine” directly into portals placed painstakingly into these tiny arms and hands.  Their mothers snooze beside them in bed, periodically swatting away flies. The nurses sit down for perhaps the first time, wipe their foreheads and upper lips, and begin to write out lists for the next round of medications due. The periodically glance at their cell phones, hoping for news or a familiar voice, knowing it will be 14 long days before time off to see their children or family again.

The hospital support staff-the broad chested, toothless women who boil enormous kettles of rice in the kitchen, the old man who drags a mop across the concrete floors, the ambulance driver, and registrers can be found napping on wooden benches, beneath trees, or can be seen walking slowly, down the hill, heading home for the day. Some remove plastic bowls from tucked away corners and eat the midday meal of rice, dry fish, and red palm oil.

Every thing seems to move slowly or even stand still; between the heat and effort spent to complete the morning routine, even the roosters are subdued, and take pause from their otherwise incessant squacking. At the nurses dorm it is also quiet, save for the sound of a radio, bringing BBC Africa news updates detailing the siege in Abijan, or the declaration of Libia’s no fly zone. Smoke curls from behind the building, where someone has lit a coal pot fire, signaling that the night shift crew is now awake, and preparing to cook, do laundry, and cold iron press their uniforms. The day seems to be ending, beginning, and staying the same all at once.

Mamma Ellie, We Welcome You!

2.26.2011

My second night in Robersport was when Madam President Ellen Johnson Sirleaf came to town. Her visit had been forecast ed to occur earlier that week, perhaps on Wednesday. But each day the reports in town circled the message relayed from Monrovia that the impending visit would occur later that day, or then, tomorrow. Saturday morning we saw that perhaps the degree of suspicion that her arrival would actually occur that day was increased, as evidenced by the furious raking of yards to hide any litter or trash, and a last minute effort by the town of Robertsport to paint “curbs” and lines along the parts of the road that involved pavement. Young boys rushed about town with buckets and rags, smearing paint along the perimeters of the road, and placed dashes down the middle. Never mind that not one of the lines was the same size or even in proportion to the others. I saw that the paint was so watered down, that it would shortly ware away, so, why worry?

We walked through town, noticing a degree of anticipation. Childrens' choirs were rehearsing. Crowds congregated at the intersection of the town’s main road, and the only road leading in. Children ran to the high points on the bordering hill to watch for the road dust indicating an approaching motorcade. Right on time (African time), the line of security vehicles began to arrive, as the sun turned red and dipped low. We watched the commotion from a shaded roof top, waiting for the sun to drop completely before we ventured down into the heat and dust. After a visit to the town sports and youth center, a wire and tin building with a playing field worn to dirt by the constant pounding of young footballers’ feet in what seemed to be a never ending match, in play day in and day out, the presidential vehicles paraded through the main street, making its way to the town hall, where the address would occur.

Robertsport citizens were understandably excited. It was now very dark and the energy level of the crowd rose in proportion to the approach of the SUV identified to be carrying Madam President herself. The security team maintained strict watch, preventing people from crossing the street and approaching vehicles. I was photographing the groups of children waving braided palm banners, and was startled to be asked to show the security director all pictures on my digital camera. I was worried that they were going to try to take it from me, but they calmly, without expression, informed me that I just needed to delete any images of security, presidential vehicles, or staff. And yes, I should do it right now, in font of them. This one, and this one, that one is ok, and so on. Done and done. No problem. 

As we turned the corner, following the line of foot traffic that flanked the motorcade on its way to the town hall, I saw a group of women wearing white T-shirts, covered in marker pen lettering, and homemade banners proclaiming “Stand by Me, Women in Development-Rights and Skills for the future”. These women were chanting and stamping- old women with gray braids, young women with infants on their backs and hips, linking arms with each other, their voices rising above the crowds, harmonious. Small children clapped along, mimicked their words and movements, beaming at their moms, perhaps unsure of their cause or reason for passion, but excited none the less.

I felt a switch turn inside me, and my footsteps brought me to stand in front of them, before I even could consider what I was doing. Like a dummy, I smiled, and shyly waved, then leaned to one of them who was curious enough to make eye contact with me and said, “I like your group, I like what you are doing”. That moment was like in kindergarten, when you take a risk and wait to see what the other kids are going to do in response. I watched her dark eyes consider for a moment, me, a tall, white stranger, distracting her on a very important day. The corners of her mouth quivered, then turned…up at the edges, into a smile. That smile was like a warm rain for me; it spread slowly across her face, revealing beautiful cheek bones and perfect teeth. She reached out, pulled my arm and drew me into their midst. It was all I could do to wave to Rob on the way in, hoping he would see what was happening, realizing that though the town was small, I barely knew it, and could easily get lost.

The inner circle was loud and raucous. I clapped along with their chanting, but my new friend wasn’t satisfied. She slowed down the words to their song, enunciating each word, teaching me patiently. “Ma-ma El-lie, We will-come –yooo…”I parroted. Like a baby learning to talk, I made the sounds. Slowly it dawned on me what we were saying. We were welcoming the president! I got it, and sang loudly, clearly. My friend nodded approval, and then I saw that the others were smiling around me to. They pointed to me, when they said the words “welcome you”. I pointed back to them, humbled. They kept me with them all the way to the hall...saying, “you are with us now…We stand by each other, for women…for rights”. We got separated at the door, as my messenger bag again drew suspicion from the presidential security. Not wanting to disrupt these women in their effort to be recognized by Madam President, I waved them on. It was for the best, I found Rob again, and we found a corner inside the hall to squeeze into and wait for Mama Ellie to speak.

Madam President of Liberia is a regal woman; savvy, incredibly charismatic, and an excellent speaker. I observed, with awe and consideration, the way she engaged the entire crowd. Men cheered her on, emphasizing their agreement with a traditional cow’s horn instrument. Young people, in flip flops and T-shirts glorifying American rap music icons dropped their cool aloofness, stood straight, smiled, and nodded when she directed them to pursue their education with a hungry heart and a disciplined mind. Of course the women loved her, and she acknowledged them by shouting “Ladies, my sisters, thank you, I Stand By You Too!”  Of course, I cheered, happy for them.

Madam President’s visit was a quite event for this town, and for me. I am humbled and thankful to say that I got to meet her, both that night at the event, and the next day, when she made a surprise visit to St. Timothys Hospital. Being in Liberia for a whole two days, I did not feel even close to deserving, but am glad that the county superintendent made her aware of the hospital project and that it seems to be to her liking.

Weeks later, having settled into a routine, I was walking home from an evening swim, and heard a familiar cadence coming from a yard behind me. I looked up to see 3 women, braiding each others hair and waving to me…calling, “we welcome you…” 

This time it took me less then a second, the words came to me and I was at their side, laughing and shaking hands all around. “I told you, you are with us now”. My friend from that night reminded me. It was her yard we were sitting in, underneath a hand painted sign that said “Beauty Salon-Woman Entrepreneur Site”. I nodded my head, so touched I could only manage “Yes, I am.” 

They asked me how things are at the hospital, and we talked for a few. As I continued up the hill, I could not help but smile, warm from the walk, but more from the glow of those smiles reflecting back at me,  pure human connection and kindness.

A Small Corner of The Earth

The first two days in country were spent shopping for house supplies, dipping in and out of crowded, dirt floor markets along the crooked streets of Monrovia, and picking up licenses to work from the Ministry of Health.

The heat and street dirt combined to make a sweaty paste across foreheads, underarms, and staining our clothes with red, damp creases. Traffic crawls through the narrow streets of Monrovia; motor cycles with two to three passengers and the daily market haul, Toyota van taxis packed to the brim, people turning their faces against the smeared windows to find their own corners to breathe, constant lines of white SUVs displaying every NGO emblem, and crowds of people, pushing this way, then suddenly that way. Vendors wield goods for sale in front of car windshields. Others carry food items; live chickens, stacks of cell phones, toilet seats, bike tires, cardboard palates displaying wash clothes, sunglasses, and bins of recycled clothes items.

These drums of clothing are filled with the sort of things mass produced for western discount chain stores, manufactured in export processing zones of Southeast Asia, and now for sale in outdoor markets of West Africa. Some are donated by Goodwill, Salvation Army charities, shipped in containers with other goods to a local Liberian merchant where they are sold street side in places like Waterside, Rallytown, or Dulalla. Some are the after season items that do not sell of the sale racks. Others are second quality, printed backwards, inside out, or with zippers in not quite the right place. Some are simply imported by Chinese or Lebanese wholesalers. Regardless of where they are coming from, it is highly possible to spot a 23 year old in full on hip hop wear, with a T shirt printed inside out that reads, “Baby bump here”, with an arrow pointing to his belly button.


Finally, as the merciless sun began to move to a lower position and cast gentler shadows across the city, we loaded up and began the traffic bound crawl. Slowly working our way out of the city, we headed towards Grand Cape Mount County, and Robertsport. Transportation was thanks to a new Spanish friend, who gave us a ride in his “Africa mobile”, a rugged vehicle converted to accommodate his overland camping road trip through the region, sampling west African languages, music, the dry dessert and misty rain forests,  and at this time settled in Robertsport in search of great surf.

During the 3 hour drive from the capitol to our little fishing town destination, we three shared good humor, a chocolate bar, cassette tapes of local West African music, and presented the same story to each security check point officer, rationalizing our presence and car loaded down with supplies. We rolled down the windows and were lulled by the truck engine, the circulating air, and the waning sound of Monrovia disappearing behind us.

Despite it being the dry season, the countryside is very green.  The town crouches along the beach, up the sharp, red dirt hillside, past cement and corrugated tin covered houses to where the hospital sits overlooking it all, underneath waving palms. The houses and other structures look eerie, almost haunted. Faded paint, open walls covered in lichen, with grass and vines spurting up and around the remnants of manmade construction, like ruins…ruins from grand days gone by, quietly standing, while a sleepy fishing town still ravaged and stunned from years of war goes about its daily business of catching fish, running market tables, and hauling water.

These buildings appear temporary,or in various stages of reconstruction, though really, very little work is being done. Families live, have been living, in these broken down interiors for generations, sometimes planting vines and herbs in paint cans to line the falling down concrete steps, or to set in the arch ways of cavernous doorways.

Some buildings are scared by bullets, some still bear the sprayed paint slash markers or graffiti, made bade various rebel groups that moved through the town multiple times during the war years. These homes and their inhabitants were ravaged over and over. I am told that each group would come and loot-the first wave taking valuables and food staples, furniture, and livestock.  The second wave would strip the light bulbs, doors and windows, roof materials, terrorizing families in their midst. When there was nothing left for the next wave of rebel soldiers, young boys with guns hanging out of the back of pickup trucks, there would be anger and increased violence against the village people, who would hide in the undergrowth of the forest, sometimes for days, when the rebel caravans stormed through. If they were found, there would often be "punishment" from rebels, for having nothing left. There are mass graves throughout town, and posters reminding women that "rape was, and still is, a crime".

Today, time seems juxtaposed; nothing changes, yet there is little indication of permanence, other then the presence of familiar faces in the dirt and grass yards on a daily basis. Or, there are box houses, made of mud and straw and tin, homes with chickens and goats and worn soccer balls running wild. Any shutter or painted portion of a building that hasn’t faded against the sun and sea salt and so retains a recognizable color is some variation of azure blue. You see it here, just enough that it becomes a theme. I’ve come to equate it with this part of the country, like the ocean; I refer to it as Liberian Blue.

The beach, with long sand fingers that spread and stir the ocean inlet, breaks the rolling blue, causing cascades of white surf to circle and spread up the side of a golden shore, which runs the length of the town.  Wooden canoe like vessels with sails sewn from patches of collected plastic scraps can be seen at work early in the morning or late afternoon. The bear names like "God Children", "Afro Arab", or my favorite "Goodluck These Eyes".

Women and children line the beach, watching the skyline, waiting with plastic basins of every color, to do the work of processing the catch once the fishermen return. On good days they can be seen with whole fish balanced on heads, walking back from the beach towards the market. Other times the nets are cast from shore, and teams of men, assisted by small children, work to reel the nets to the beach. The movement is coordinated, arm and shoulder muscles moving in unison with each pull and long stroke, they drag nets full of smaller fish, and a variety of crabs, from the ocean up onto the beach.   

Fishing is the way and work of life here in Robertsport. It is not just the primary industry, it defines the culture of this small community. Most families are fishing, selling their catch in town, or drying and smoking whole fish in oven huts built off the side of their homes…with no refrigeration, this is the only way to preserve the fish. Most meals are made with some variation of a broth, seasoned by dried fish, torn carefully into the pot at the beginning of the cooking processes. Other ingredients seem to be the all powerful Maggi bullion cube, onion, red Argo oil, and dried red pepper.

Mornings are characterized by fishermen convening silently on the beach, unrolling their sails, made simply from patchwork sewn plastic, wrapped with plastic twine around a simple bamboo mast and boom. Midday, the beach is rather empty, save for the random swimmer, or perhaps the fishermen napping beneath their overturned boats, waiting out the heat of the day until its time to push their boats off the beach again, for the evening catch. Smoke curls from the huts at the edge of the beach, where the wives of Kru Town are working away to preserve the fish, reading it to sell or use.

On Fridays there is the early morning call to the town Mosque. On Saturday evenings, the gospel choir rehearses at the town hall. Sunday Mornings, people dress in lace and traditional print fabric wraps and dresses. Men crowd and lean forward around domino tables, telling stories in Vai, Gola or sometimes English, sharing bottles of Club beer, waiting for the relief of the evening breeze.  During the weekday afternoons, around 1pm, you see the school children in royal blue dress uniforms stream down the hillside, through town, stopping at roadside stands to buy a plastic bag of water, a donut from a well worn plastic jar, picking their way home. Evenings are quiet. The heat relents slightly, casting soft shadows. Cook fire smoke laced with red pepper fills the air. Children gather and hang on the side of the water pumps, playfully swimming the level up and down, to fill containers of every size, or, can be seen going to the streams. They balance plastic buckets and drums on their small heads, glancing sideways at you to say a shy hello, their expressions serious, ever conscious to avoid spilling a drop.

Roosters crow at all hours of the day and night. Dogs bark and scuffle in dirt yards, nipples sagging, their backs scraggly with wild fur, or bare, depending on their condition. People call to each other on the road, into each others' windows, or argue from yards away. Radios blare BBC Africa or remixed R&B songs. Children pull toy trucks made out of plastic bottles with bottle caps fastened for wheels with bits of twine, spin bicycle rims in front of them with sticks, or pound tomato cans as drums.

The generator to the hospital on the hill kicks on after dark and whines through the night, and sometimes, the babies in the pediatric ward stop crying as they are rocked to sleep. Far away, down the hill, at the edge of town, waves lap and pound the beach, keeping rhythm and time, always.

West Africa-Let's Go!

Headed out today to begin another story. This new chapter will be out of West Africa. Those who know me may recall some foreshadowing leading up to this, based on past tales. I'd like to think of this story as a choose your own adventure type, but more and more I believe that life pulls us along a path, despite ourselves. Sure we make choices at forks in the road, but this story is truly writing itself, and I am an eager page turner.

So, here I am, a girl whose primary home is Portland, Maine, trading fur lined boots and the remaining ski season for sandals and a mosquito net, and departing for another small fishing town, on the west coast of Africa.

The destination is Robertsport, Grand Cape Mount County, Liberia. The plan is to work at St. Timothy's hospital as part of a start up, hospital capacitating project. As a nurse with a love for Africa, for community development through health, and whose happiest moments ever are about seeing something built, by and for groups of people who benefit by getting their basic needs met, this project speaks to me. There are things that sometimes we do because try as we can, we can’t fully justify why not. Deep down I said yes, and so signed on to help.

The how to all of this, as the seasoned and therefore cynical Relief and Development community knows, is what will ultimately define whether or not this project will be successful. Will it capacitate local Liberian health care workers, assist in improving the hospital, contribute to strengthening of the health system, referral process, and ultimately benefit the community? It’s going to take a lot of time to tell.

This project was conceived of by a traveling doctor who found, in Robertsport and this hospital, a place that not only shares his name but that seemed to be the right place to try to launch what had been, until now, a harbored dream. He is a persuasive fellow, recruiting other like minded health provider nomads to get this project off the ground, and keep it running. It’s been over a year in planning for him, connecting with local partners, including the town leaders, hospital administrators, and Ministry of Health. Imagine the feeling, when he returned to Robertsport at the beginning of this month and began the process of putting plans into action, and people in the community began to say, "hey, you came back, just like you said you would".

This will be my first time in this part of Africa. Liberia has a unique history; a slightly different story than the common European colonial, post colonial quagmire. But, just as troubled, and deeply intertwined with US politics, history of race relations and socioeconomic structuring, and most recently, commodity interests during the Liberian civil wars. I remember first reading about the chilling Charles Taylor presidential years, blood diamond geopolitics, rain forest destruction, ruthless rebel factions, horrific violence, use of rape as an act of terror and retaliation along ethnic lines, and abuse of children as forced child soldiers. I remember, vividly, the news footage documenting the masses of Liberian people who made a panicked pilgrimage from the countryside into the capital, Monrovia, as the warring rebel groups raged and violence culminated, the Taylor regime was finally ousted, peace negotiations began in neighboring Accra, and the UN troops descended upon the city. The stadium was where Liberians went, for safety, to be guarded by the UN. The stadium became a refugee camp, with all the inherent challenges that a camp setting creates. Waterborne illness, communicable disease, food distribution tensions, all the safety issues.

Today, Liberia is at peace, and still struggling to cope in everyway with the aftermath of 2 decades of internal conflict. There is a democratically elected president, the first female head of state in Africa. The job of rebuilding, as in any post conflict society, is staggering. For me health, and community development through health, is not an isolated need. Education, job training, income generation, are the other legs of the stool, without any of these the structure cannot stand. But, I do know that poor health makes anyone of these other needs impossible to meet, and can drain resources from a family or community instantly. The death of a mother due to a preventable illness or emergency health need impacts her children and that family in ways that may be quantifiable, but really cannot be fully measured.


So, I guess it’s on. Whether through community based, public health interventions that focus on behavior change and education or curative, clinical nursing, there is a lot of work to be done. West Africa-Let's go!

Yebo What?

Let me explain the meaning "Yebo World". When I was 19, I spent 5 weeks in South Africa-Cape Town, The Eastern Cape, Kwazulu Natal and Durban. I fell in love with Africa; the people I met and the work that I did has guided each step taken since. Here I learned the word Yebo, which means "Yes" in Zulu. It also has the meaning of "Hello" as a reply to Sawubona, which means "greetings" in Zulu.  

"Hi!" - "Yebo"!

"Shall we go?" - "Yebo!" 

I heard my host family say it, high in the hills, early in the morning as the chilly mist that surrounded the roundaval houses cleared, and children called to the women cooking, asking them to bring more water. "Yebo!"-I am coming. I heard it on the streets of Durban, people rushing and pushing, carrying books and chickens and crates of dried goods onto overstuffed taxi vans, shouting into their mobile phones, "Yebo? Ahhh, YEBO!" to greet a friend.

Five Years later I returned to South Africa, and to Kwazulu Natal. This time I returned as a nurse intern, and "Yebo" filled the hospital where I worked. Is the water turned on today? "Yebo!" Can I listen to your lungs little boy, don't be scared, there you go, Yebo! You might remember hearing this word, during last year's World Cup. If a goal was scored in South Africa's name, the whole stadium would vibrate with the sound of "Yaaaay-boh, Yaaaay-boh".

I've worked, visited and been enamored with many other places, in central Africa, Asia and beyond, but this Zulu word will always be a quick reminder for me of all that can happen when you greet and say yes to the world. One other small side note, because of the Bantu language base throughout Africa, I happily found in Rwanda the name for yes to be a familiar sounding, “Yego”.

Yebo has stuck with me over the years and continues to resonate. Its seems that saying yes,and greeting the task at hand is always the right answer.