Negative

Patrick

Depending on the test, depending on the person, a negative test result can signify disappointment and sadness, or relief and joy.

A negative HIV test, however, particularly that of a new baby born to an HIV positive mother, can surely only be a cause to celebrate. We learnt that Patrick’s first HIV test was negative on 5th October 2011. Since we had a team in Ipusukilo on that day, we were able to share this news* with Christina almost immediately. I was not there to witness her reaction, I wish I had been. The good news was imparted by Legzai, the MSF Counsellor who by now knows Christina’s story quite well.

He told me later that she was ‘happy’. I remember her inscrutable reaction when she learnt of her HIV positive status in March 2011 – a reaction that masked a thousand fears. Knowing Christina as a shy and introverted person, I’m sure that the happy reaction witnessed by Legzai was typically subdued; but knowing also how worried she had been about Patrick, the test results will have inevitably provided her with elation and peace of mind.

In the last week, I have also learned that Patrick’s second HIV test, performed in December at six months, was also negative. We recommend our PMTCT (prevention of mother to child transmission) mothers to breastfeed their babies until they are one year old (introducing solids at 6 months). He will be retested at one year and then finally at 18 months.

I hope to see the family again before then. In December, I finished my mission with MSF in Luwingu and returned to England, but my Zambian story will continue – albeit with a different organisation. Thank you for sharing Christina’s journey with me. If you would like to stay in touch, don’t hesitate to contact me through this blog. Natotela and shalenipo! (thank you and goodbye in Bemba).

*Christina had to wait months for these results, despite the fact that the test itself yields results in less than one day. Babies must be tested using a different test to adults (which can be done on the spot and yield results in a matter of minutes), and samples from Luwingu must be sent around 200 miles away to Ndola in the Copperbelt. The courier service responsible for transporting these samples has unfortunately been largely responsible for these unacceptable delays.

Posted in Field Coordinator, HIV/AIDS, Zambia | Tagged , | 8 Comments

New Life

I learn that Christina has delivered from David the Lay Counsellor, who calls me to tell me so. The line is bad, and although I establish that she delivered at Ipusukilo rural health centre on 3rd June, that the baby is a boy and both he and Christina are doing fine, I cannot confirm for certain that the infant received Nevirapine at birth. It is during delivery that a baby born to an HIV positive mother is most vulnerable to infection, therefore it is crucial that Nevirapine syrup (anti-retroviral prophylaxis) is administered as soon as possible to minimize the risk of transmission. By now I know where Christina lives, so on Sunday 5th June I journey out to see her, in the company of Anthony, the Clinical Officer who has been attending to Christina since she was enrolled on the PMTCT programme.

Patrick

Patrick

The arrival of a vehicle, particularly one with a musungu (white person) inside, attracts curious children, dusty and barefoot. They seem to appear out of the bushes, from all directions, their clothes hanging off them in scraps. The family is not expecting us, but welcomes us enthusiastically, particularly Christina’s mother Joyce, who claps her hands and clasps me in a bone-crunching embrace. Christina emerges from the house, wearing the same batik dress she was wearing on the first day I met her. It is a huge relief to see her up and smiling.

She quickly leads me into a room inside the family’s thatched hut, and introduces me to a bundle of blankets and pink and white knitwear – Patrick. Newborns are packed in so many layers here in Zambia, it’s hard to make out their actual size. On arrival at the maternity ward at Luwingu District Hospital, it’s not clear which are the babies and which are piles of blankets. Invariably, what looks like a pile of blankets is usually a baby – approach a bed and the mother will fold back the blanket to reveal a tiny wrinkled face. The women’s fear of the baby getting cold clearly outweighs that of the baby suffocating. Patrick is lucky enough not to have his face covered, but he is wearing a pink hat – Christina had made no secret of the fact she was hoping for a baby girl.

Christina and Patrick

Christina and Patrick

He has been named after a brother of Christina’s who died in April last year, aged only 40. Christina is the fourth of eight children, and all three of her older siblings have died in adulthood, in the same order that they were born. When I first met Joyce back in March, she lamented that Christina was next. When I had asked her how her children had died, the answer was simply ‘ubuloshi’ – witchcraft. As my relationship with the family has developed, I have been able to delve a little deeper. The first, I learn, had ‘malaria and hiccups’. The second had the misfortune to lose his wife to his younger brother, an affair which brought him bad luck and eventual death. The implication, I later learn from Legzai, the Counsellor who translated the conversation, is that the younger brother put a spell on the second-born, so he could continue the relationship with his wife. Indeed, when he was out of the way, the couple later married. Patrick, the third to pass away, had something moving in his stomach which couldn’t be seen by medical professionals. Since modern medicine couldn’t provide any answers, the family took him to see a ‘ng’anga’, a traditional healer. The ng’anga informed the family that Patrick had received magic as a child, which had caused this stomach problem later in life.

Fortunately, Christina does not believe that ubuloshi can cause HIV/AIDS. HIV/AIDS is not considered an African disease in Zambia, and most ng’angas do not claim to be able to treat it. But many people do not want to learn their HIV status in the first place, or do not readily accept that they are positive, which is hardly surprising considering the stigma and discrimination that continue to surround the virus. Such people may prefer to consult a ng’anga to get an explanation for their aches and pains; they may even prefer to learn that their neighbour has cast a spell on them, rather than that they are HIV positive. A ng’anga will not perform an HIV test, and an unscrupulous ng’anga will prescribe traditional medicine even if they suspect their client is HIV positive. In Zambia, ng’angas practicing centuries-old African medicine are present in almost every village, compared to sparsely distributed health facilities, often lacking staff, medicine and equipment. In this context, Christina’s determination to stick to her treatment, to ensure that Samuel takes his treatment, and to walk several kilometres in the dark, whilst in labour, in order to deliver her baby in a health facility, is highly impressive.

Impressive still is the fact that not only did Patrick receive his Nevirapine, but that it was Christina who reminded the staff assisting the delivery that he needed it. Just as for the births of her previous three children, there were no qualified health personnel in attendance, just one CDE – ‘Classified Daily Employee’ – Theresa. In fact, if you leaf through the delivery register at Ipusukilo rural health centre, you will see that most of the deliveries that take place at night are attended to by Theresa. And this is despite the fact that Ipusukilo is luckier than the more remote facilities in the district, in that the Ministry of Health has assigned two qualified health staff there, a Clinical Officer, Martin, and a Nurse, Memory. But Martin and Memory are not always available to deliver babies at night; they may have been on duty all day, they may be on leave, or at a workshop, they may have malaria, and besides – Theresa had been delivering babies for years before Martin and Memory showed up, so what’s the problem? This is one of the many contradictions MSF has to grapple with every day at field level – the Ministry of Health does not officially endorse CDEs to conduct deliveries, however CDEs like Theresa are doing deliveries, night after night, day after day. There are simply not enough qualified medical staff in Zambia. Even if MSF wanted to staff the rural health facilities ourselves, 24/7, it is highly unlikely that we would be able to hire enough trained health staff willing to live and work in such remote areas, far away from their family and friends.

So on we go, trying our best to work within a far-from-perfect system and figure out the most constructive ways to support it. It didn’t take me long to realize that this is a far bigger challenge for MSF than if we were able to just take control and do everything ourselves. In this setting, the rewards come more slowly, some imperceptibly. At this delivery, Christina knew what she had to ask for – and although that may not be quite the way we want things to work – this reward will sustain me for a good while yet.

Posted in Field Coordinator, HIV/AIDS, Zambia | Tagged , , , , , , | 1 Comment

Milou

We all agree that the dog looks like Tin Tin’s dog, but nobody can remember his name. There is silence while we rack our brains, and suddenly Agnès blurts out ‘MILOU!’ Yes. Milou. In English translations of Tin Tin, he’s Snowy, but since my acquaintance with Tin Tin is based on summers spent in Brittany as a teenager, where my French host family had stacks of Tin Tin books lying around their rambling Breton farmhouse, to me he’s definitely Milou. And to Agnès too, since she’s French.

Milou is not new, evidenced by his dirty white and dishevelled coat, but he doesn’t look like he has been any child’s favourite toy yet either. He is a gift to the Luwingu project from an MSF Water and Sanitation Specialist, Paul Jawor, who has sent over 50 second-hand soft toys to MSF projects around the world. His instructions are always the same: to photograph the creature on location with a variety of exotic backdrops, and finally to award him (or her) to a deserving child. He plans eventually to compile the photos into a series of children’s books. So Milou accompanies us on a weekend away to Lumangwe Falls, a spectacular waterfall about 100km northwest of Luwingu as the crow flies. He swims dangerously close to the 30m drop, gets car sick on the bumpy roads and tries his first nshima, Zambia’s native cuisine. And then he is back on our bookshelf, neglected, and it is time to find that deserving child.

Milou at the Lumangwe Falls

Milou at the Lumangwe Falls

The deserving child I have in mind is Samuel. When I last saw him on 30th March, he was suffering from an ear infection, and he screamed in pain when the clinician looked into his ear with an otoscope. His CD4 count had come back as 479, indicating the need for him to start ARV treatment (children with CD4 of less than 750 should start treatment), however he needs to be initiated at the hospital in Luwingu, and last time Christina couldn’t take him because her mother, Joyce, was not well and unable to watch the remaining children. At this last appointment, Samuel was given Amoxicillin for the ear infection, but I regretted that his referral to the hospital for treatment was delayed by another two weeks.

So today, 13th April, I am determined that Christina will take advantage of a lift from Ipusukilo to Luwingu District Hospital in an MSF vehicle in order to have Samuel assessed for treatment. I accompany her to the consultation room, where she tells Anthony with a shy smile that she frequently feels the baby kicking, and she’s given another month’s supply of the combination pill (TDF/3TC/EFV), which she is taking at 7 o’clock every evening, and which we all hope is pulling up her CD4 count. Since the CD4 count typically only increases by 5 to 7 per month after the onset of treatment, her blood is not re-tested at this stage. She agrees with the suggestion to bring Samuel to Luwingu for assessment, and the two of them are bundled into the MSF vehicle along with another HIV positive mother, her baby and a young, very sickly looking daughter.

Christina is proving to be a perfect patient. To date she has not missed a single appointment, and she seems to be adhering to her treatment without any difficulties. Considering the problems we have faced (and continue to face) with defaulters, it’s gratifying that the first PMTCT (preventing mother to child transmission) patient I was introduced to happens to be this sensible and intelligent woman. Others have cynically pointed out that it may be the curiosity value of a mzungu at each and every visit which keeps bringing her back. Jeanie, less cynically (but quite unrealistically), wants to write me into our defaulter tracing strategy – she suggests that if every patient was given the individual attention that I have given Christina, then they would be less likely to default.

I’m not convinced. Two key elements of Christina’s personal circumstances mean that she was less likely to default from the very beginning, without me even entering the equation. First of all, she can access Ipusukilo rural health centre relatively easily by foot. MSF is supporting six other rural health centres (RHCs) in Luwingu District, and some patients have to walk many hours to reach the closest one. Considering that our PMTCT patients are either pregnant or have young babies, it’s not surprising that long distances on foot are an obstacle to their participation in the programme. Secondly, Christina has a supportive family. Although her husband is absent (ever since I first met her, she has always described him vaguely as being in the Copperbelt visiting relatives), her mother has opted to be her treatment supporter and lives with some of Christina’s siblings close by. We are losing an unacceptably high number of women because their husbands or other family members do not support their participation in the PMTCT programme, but fortunately this is not a situation faced by Christina. I know it’s wrong to stereotype, but I don’t relish the return of her husband in case he turns out to be yet another husband who blames his wife for her HIV status and forbids her to return to the clinic.

We have a number of strategies in place, and some more in the pipeline, to address the issue of women defaulting from the PMTCT programme. In addition to three MSF Counsellors, one per medical team, we also work with a network of Lay Counsellors, such as David Mapulanga, who are based at the MSF-supported RHCs. They are trained in HIV testing and counselling, and often they are the ones to disclose HIV positive test results to pregnant women. They establish a relationship of trust and a culture of confidentiality with the PMTCT clients. In some locations, the Lay Counsellors have established support groups for women enrolled in the programme and other HIV positive community members. New members benefit from emotional support from those who have accepted their status, who may provide the proof they need that an HIV positive woman can give birth to a healthy child, and that being HIV positive doesn’t mean imminent death – that with the correct treatment it’s possible to live a normal, healthy life.

In the case of defaulters, if a woman fails to turn up to an appointment, her name will appear on a list of defaulters, and it is the responsibility of the Lay Counsellor to track her down, find out her reasons for missing the appointment, and, if appropriate, counsel her to come back. If it is the husband or family who are proving to be the obstacle, then the Lay Counsellor can use the home visit to try and educate them on the importance of the woman’s commitment to the PMTCT programme, and the benefits of voluntary counselling and testing (VCT) for all sexually active individuals. Until recently, the Lay Counsellors have complained of the difficulty of reaching all the defaulters on their lists, since many of the clients live so far from the RHCs. For this reason, we have provided them with bicycles. While we do expect increased mobility of the Lay Counsellors to have a positive impact on the defaulter tracing, we cannot pretend it is a magic bullet – after all, it does not provide a solution to the lack of transport options available to the women themselves.

The issue of distance from the RHCs has been a concern since the early days of the project, not only for the women enrolled in the PMTCT programme, but for all women needing to access the sexual and reproductive health services on offer – including antenatal and postnatal consultations, family planning and safe deliveries. Most women in Luwingu do not plan to deliver in a health facility, because of distance but also because for such a long time the RHCs in this district have been without qualified medical staff. When MSF arrived in Luwingu in May 2010, there was only one qualified medical staff working in one out of eight of the RHCs in the district. In the early months of the project, MSF lobbied the Ministry of Health to allocate qualified staff to these centres, which resulted in at least one Nurse being posted to seven of the eight RHCs. The presence of qualified staff meant that we could start to encourage pregnant women to come and deliver at the centres, instead of in their homes. However, without confronting the issue of distance, this was an unrealistic expectation.

In January of this year, we started to pilot test the ‘Zambulance’ (photo below), a bicycle ambulance trailer. We donated eight of them, 700 USD a piece, to eight villages each between 15 and 25 kilometres from the nearest RHC, with the objective of transporting labouring women to the closest RHC. The Zambulances, which were donated to community ‘SMAGs’ (Safe Motherhood Action Groups), are having modest success (so far we know of 34 referrals), and we are currently considering whether or not to purchase more of them. Unfortunately, however, there are many thousands of women in Luwingu District whose homes are unreachable by Zambulance – either because of the distance or the condition of the road.

A Zambulance

A Zambulance

Which leads me to one of the strategies in our project pipeline: to establish a ‘Mothers’ Waiting Shelter’ at each of the RHCs. I remember a Midwife colleague of mine describing these to me last year in Haiti, but having never worked in a project which involved encouraging rural women to deliver their babies in health facilities, I failed to grasp the significance of what she was saying. A Mothers’ Waiting Shelter is a place where women who are in the last two to four weeks of their pregnancy can come and stay until they deliver, thereby ensuring that they will deliver with a health personnel in attendance. Certain women require a higher level of care during their delivery (for example if they have had complications during previous deliveries), so if they come to the shelter in good time, then they can be transferred to Luwingu District Hospital. During my time in Luwingu, I hope to see the impact that such a shelter can have in terms of the number of women choosing to deliver at health facilities rather than at home.

As for Christina, she plans to deliver at Ipusukilo RHC, just as she did for her previous three children. Although these were not in the presence of a qualified health staff (there was a ‘CDE’ in attendance, which stands for Classified Daily Employee, not medically trained but the stalwarts of the RHCs before the Ministry of Health posted qualified staff), she was still satisfied with the service she received. Her delivery will, more than likely, take place when MSF’s team is not at Ipusukilo (since this RHC is only 15 kilometres from Luwingu, we only visit on a fortnightly basis). This means that it will be the Ministry of Health Nurse or Clinical Officer (Ipusukilo is the only RHC in Luwingu with a Clinical Officer) who will be in attendance at her delivery. They have been trained on what to do if an HIV positive woman comes there to deliver; in Christina’s case, this will mean administering Nevirapine syrup to the infant as early as possible after delivery (and daily for six weeks afterwards), and ensuring that Christina continues taking her medication as normal. Christina also knows that the baby will need medication when he or she arrives. The delivery is the most dangerous time for the baby in terms of exposure to HIV, so it essential to get this part right.

Despite doing everything right, Christina is naturally worried about transmitting the virus to her unborn baby; but before he or she (she’s hoping for a she) arrives, her focus is on Samuel. When I present him with Milou before we set off for the hospital, he accepts him warily. By the time we arrive, however, he is clasping hold of him tightly, as if he never wants to let him out of his sight. While a man at the hospital starts to ask Christina questions, neatly filling out the first of what I imagine will be dozens of papers about Samuel’s health over the next few years, I am for the first time ever witnessing him behave like a child. I’m not attributing this to Milou, or to myself, I’m just delighted to finally see him smile and giggle, turn round and round in circles, jump up and down, organize empty pill boxes on the window sill and then knock them all down, and just generally entertain himself. Unfortunately, these moments are short-lived, since Samuel needs to have blood taken for a series of tests that are required before he can be initiated on treatment. While the handsome Laboratory Supervisor, Mr Bwalya, breaks out into a sweat trying to locate a vein on his chubby hand, Samuel is once again screaming and crying, this time repeating over and over ‘Nakana! Nakana!’, which Mr Bwalya wearily translates as ‘I don’t want’ in Bemba.

On the same day I am privileged enough to see Samuel enjoying carefree, childish moments, I also realize that it is the first day I have seen Christina looking really, noticeably pregnant. In fact, she is now enormous, invigorated and blooming. Today she has brought me a bucket of groundnuts from her own harvest, and as she picks at them and tosses the shells over her shoulder, I wish I had the words in Bemba to tell her how beautiful she looks.

Christina and Samuel

Christina and Samuel

Posted in Field Coordinator, HIV/AIDS, Zambia | 6 Comments

Intanda Bwanga

On Wednesday 16th March, Christina is due for her next appointment at Ipusukilo rural health centre. I travel with our medical team, arriving before 9 o’clock, and scan the faces of the women who are already waiting. I can’t see Christina amongst them. I reason that since she lives close by, perhaps she’ll wait until she or a neighbour sees the MSF vehicle arrive in the village before setting out.

Ipusukilo rural health centre is a shadow of what it once was. This was a mission hospital, with a large in-patient capacity and probably several dozen staff. Before Luwingu District Hospital opened, I’m told in 1965, this was the referral hospital for Luwingu District’s estimated population of 139,000. Today, most of the former hospital buildings lie eerily abandoned. In some rooms, rusting bed pans or medical notes which have gathered years of dust lie strewn across the floor. The scenes here take me back to Sierra Leone and Liberia, where I have seen endless derelict buildings consumed by nature – former banks, hotels and offices no longer serving their original purpose, their open doors and broken windows instead welcoming curious wild animals and birds, not to mention a steady trickle of individuals and families seeking shelter. Zambia, unlike these countries, has not seen more than a decade of war and the associated mass displacement of its citizens, and these buildings show little evidence of human occupation. But squatters or no squatters, there’s something very depressing about a formerly bustling hospital left to decay in this way.

Today the health services on offer at Ipusukilo rural health centre only occupy half a dozen rooms of what was once a large complex. Therefore it is not difficult to find an empty room in which to hold my pre-arranged meeting with some of the local Headmen (and one Headwoman!) who have travelled from the surrounding villages. I realize when I enter the room that I was not expecting such a high attendance, there are at least 15 people waiting for me – a few of them very elderly men and many of them dressed in what looks like their Sunday best. My Bemba greeting ‘Mulishani!’ is met with appreciative laughter, meanwhile I’m pretty mortified that all of the more formal greetings that I was recently taught have escaped me at just the moment when they would be extremely fitting. One of the Headmen, a tall man called Eugene, offers to translate for me, and the meeting kicks off.

Headmen and women

Headmen and women

I planned this meeting with the intention of introducing myself as the new Field Coordinator for MSF’s Luwingu project, and explaining what MSF is doing in the district. I have been told on several occasions that local acceptance of our interventions will improve significantly if we have the support of traditional community leaders such as these, therefore I’m determined that they will leave with a favourable impression and clear understanding of what we are trying to achieve here. Through Eugene, I explain that MSF is an international medical and humanitarian organisation, working in over 70 countries worldwide to alleviate suffering of vulnerable populations affected by war, natural disaster and poor access to healthcare. I tell the gathering that MSF has worked in Zambia in different regions and capacities since 2001, but that our activities in Luwingu District only started in June 2010, and our objective for this project is to reduce maternal and neonatal illness and death through improved sexual and reproductive health services, including the prevention of mother to child transmission of HIV. I take the opportunity to emphasise that we are not in Luwingu to set up a parallel health system to that of the Zambian Ministry of Health, but to work in government structures and to integrate government staff, so that when MSF leaves Luwingu (currently planned for 2014), the same services will continue.

So far so good. What happens next is surprising even to me. When I decide to test the water and assess the Headmen’s (and woman’s) knowledge about HIV/AIDS, I have no idea how they will react – after all most of the men are old enough to be my father and our backgrounds are so dissimilar that it may be considered positively impertinent for me to raise such a delicate subject in their presence. It therefore comes as a huge relief when my questions are not met with stunned silence but with openness and curiosity and occasionally, laughter. The collective knowledge about the most common methods of HIV transmission and prevention is far better th an I expected. However I’m also aware that I’m amongst representatives of very male-dominated communities – where women have little if any say over if and when they have children, and how they manage their pregnancies and deliveries. Although the men are quick to mention condoms as an HIV prevention method, I point out that many men in Zambia believe that having sex with a condom is like ‘eating a sweet with its wrapper on’. Since I have a sweet with a wrapper on in my bag, I pop it in my mouth. Of course this prompts applause and laughter – but my question is serious: how can a woman protect herself from infection if her husband is unfaithful and he refuses to wear a condom?

INTANDA BWANGA is what Eugene writes neatly in my notebook when I ask for the Bemba way of saying HIV/AIDS, and when I ask what this means, several people in the group indicate that it means thin. This is not surprising – even before scientists in the West decided to use the name ‘human immunodeficiency virus’ to describe the illness affecting gay men in America, doctors in several African countries had already nicknamed this new disease ‘Slim’. I ask the group what would happen to a baby born to a woman with intanda bwanga, and the response is a low muttering and sad shaking of heads. The assumption seems to be that this baby cannot be helped. It’s a good feeling to be able to explain that this is not the case, that if a woman attending an antenatal consultation is found to be HIV positive then she can be enrolled on a treatment programme which, if adhered to correctly, will reduce the chances of her baby contracting HIV to less than 5%. Furthermore, there is no reason for the woman to become ‘slim’. After she successfully completes the PMTCT programme – enabling her baby to look forward to a healthy infancy and childhood – she can continue taking anti-retro viral (ARV) treatment for the rest of her life. She may even live to see her grandchildren. Since 2005, the Zambian Ministry of Health has been providing ARV treatment free-of-charge to those who need it. Although formerly MSF was providing ARV treatment to the general population in Zambia, these days we refer them to the national programme, including women such as Christina once she has weaned her hopefully HIV negative baby.

Although the meeting has now lasted over an hour, I can’t pass up the opportunity of mentioning male involvement as a crucial element in ensuring the success of our programme – whether the woman is HIV positive or not. Decisions regarding family health are usually made by men in Zambia, however it’s a rare sight indeed to see a man accompanying his wife or children to the clinic. A Zambian woman can be showered with health education – why her family should sleep under mosquito nets, why she shouldn’t carry heavy items on her head during pregnancy, the importance of delivering her baby at a health facility – but if she gets home and her husband disagrees, then nothing will change. We have had cases of HIV positive women enrolled on our programme, who have later defaulted because their husbands haven’t allowed them to return to the clinic – in some cases they have even been beaten or divorced. Jeanie says she has not yet seen a husband accompany a PMTCT mother to a consultation, and she has been in Zambia since October. The fact that these women may be attending without the support or even knowledge of their husbands will undoubtedly have far reaching consequences – they are at risk of defaulting on their treatment or dropping out of the programme altogether, and if a man doesn’t want his wife to deliver in a health facility in the presence of a skilled attendant, then she will likely deliver at home where both her own life and that of her baby will be in danger.

As a formerly aspiring actress (and since I always used to be cast as old women, who knows what will happen in the future), I enlist the help of a couple of Headmen for some role-playing. The open-minded husband who goes with his wife (I am the wife) to the clinic, has his HIV test with her, and listens to the health professionals explain what they need to do to ensure a healthy pregnancy and delivery, versus the stubborn, authoritarian husband who stays at home while his wife is at the clinic and blames her if she tests positive for HIV, while refusing to be tested himself, who confiscates the mosquito net and pills and refuses to allow her to go back again. The ease with which the role plays are acted out and understood, despite the language barrier, indicates that the second scenario is unfortunately not uncommon. As the meeting closes, I request that we meet again in one month’s time, and meanwhile ask these important community leaders to go back to their villages to talk about these issues. As I do so I wistfully imagine them gathering the male youth in the shade of a tree and telling them to use condoms, to allow their female counterparts to finish school and decide what they want to do with their lives, instead of falling pregnant while still in their teens and continuing the vicious cycle of poverty and female subordination. I snap out of my reverie and head back to look for Christina.

But she’s still not here, and it’s past 11am. The waiting room is now crowded with women and as I examine their faces one by one, dozens of dark eyes looking back at me, I wonder if maybe I have forgotten what she looks like. I double check with Jeanie and David that they haven’t seen her, and then I decide to head back to the office because I have a list as long as my arm of things I need to do. Jeanie agrees that she will call me if Christina arrives, and I try not to panic that she has defaulted already. Ipusukilo is only a 45-minute drive from our office – if Christina shows up I can come back later to meet her.

In the end, I make it about half way back to Luwingu and I get a call from Jeanie: ‘your lady’s here’. When I get back, I head straight into the counselling room and in my excitement it takes me a few moments to realise that I’m blabbering away to two women I’ve never laid eyes on before, assuming that one of them must be Christina. When I do eventually find her, I give her the hug that I wanted to give her two weeks ago – which takes her by surprise a bit, not least because hugging is not a common form of greeting in Zambia; I remember this half-way through and between the two of us we manage to transform the hug into the more socially acceptable shoulder-to-shoulder ‘press’, on both sides, which always reminds me of greetings in Ethiopia. Then I notice the little boy who is with her, peering suspiciously up at this strange white lady who is grabbing hold of his mother. He has large brown eyes, with impossibly curly eyelashes which bend back over his top eyelids; he’s wearing pink tracksuit trousers, a blue towelling t-shirt and sandals with socks. I can make out that his little green socks have a picture of a football goal on them with a ball going inside and the misspelt word ‘goooooooool!!!’. He is gorgeous, but he has the fed up face of a sick child, and in my heart I know why. This is the 3-year old son that Christina told us she was worried about. I will call him Samuel.

Before Samuel knows what is happening, his mother has run off, and he is alone with the strange white lady. Understandably, he starts crying and potters after her in a panic. They are soon back, with Christina’s mother in tow and a little girl who looks around the same age as Samuel. After some confusion, I manage to establish that the little girl is Samuel’s cousin, and that her grandmother has just taken her to the general outpatient department because she’s not feeling well. She feels a bit hot, but looks like a healthy child, particularly standing next to Samuel who has skin rashes and swollen glands.

Before proceeding to their consultation, David helps me speak to the family for a few minutes. In the two weeks since I last saw her, Christina has confided her positive status to her mother, and it’s very reassuring that she has accompanied her today. However, the mother is feeling sad. She tells me that three of her eight children have died in adulthood, and it seems that Christina is next. Christina is her fourth child, and the three who died were her first, second and third born – they were born and died in that order. When I ask her how they died, David’s translation is simple – ‘witchcraft’. I cannot hope to challenge such entrenched views, I can only try to reassure the mother – let’s call her Joyce – that Christina is not the victim of witchcraft – she has a treatable illness and can live for many years. I recently finished reading an excellent book called ’28 stories of AIDS in Africa’ by Stephanie Nolen, and I remember a Ugandan Doctor who almost died from AIDS-related complications, but who today is fighting fit and an international AIDS professional. It struck me when she said that the first reason she survived was the love and support from her family and friends, not the drugs. And this coming from a Doctor! I suppose I’m worried that Joyce sees Christina’s impending death as inevitable, and I tell her that Christina will need her love and support in order to survive. I’m put in my place when Joyce almost snaps at me – ‘this girl knows I love her very much’. This makes me feel much better.

The consultation room is crowded with Christina, Joyce, the two children, myself, Jeanie and Anthony – a new MSF Clinical Officer who Jeanie is training on-the-job. During the medical consultation, Joyce and the little girl are in a playful mood – especially when they see my camera. Their mood is in sharp juxtaposition to that of Christina, who is sitting with Samuel on her lap, looking very worried. Jeanie is carefully explaining to her, via Anthony who is translating, that her blood test from two weeks ago has shown that her CD4 count is 248 so she must start full ARV treatment – to suppress the virus in her blood to protect her own health and to prevent transmission to her unborn baby. The CD4 cell is a white blood cell that leads the body’s attack against infections, and in a healthy person there are 1,200 CD4 cells per microlitre of blood. A person is said to have AIDS when his or her CD4 count is below 200, and the recommended level to start ARV treatment is

Samuel screams ‘mummy, mummeeeeeeee’ over and over when his finger is pricked for the HIV test, and within minutes Christina’s worst fears are confirmed. Samuel is also positive. In addition to rashes and sores on his skin, Christina says that he suffers from frequent diarrhoea. He screams and cries again when his blood is taken for the CD4 count – he will undoubtedly now associate this building with having needles stuck in him and will dread coming back here. It will not be MSF who treats Samuel for HIV, he will be referred to the national programme, however we will include his CD4 count on the referral so that the next clinician knows which treatment to put him on. Samuel is also given Cotrimoxazole, which Christina must give him once per day until he is evaluated by the national programme. Before she leaves, we weigh Christina and Joyce down with nutritional supplements formulated for people living with HIV – she needs to eat three 60g bars per day.

When I discuss the Bemba expression intanda bwanga later with some of my staff, they tell me it doesn’t mean thin, it means ‘the disease that can never be cured’. Some of them react angrily, telling me that it is expressions like this that contribute to the stigma and discrimination around people living with HIV. Most of them prefer to use the English acronyms, HIV and AIDS. I think about Samuel – he can’t articulate why he doesn’t have as much energy as his siblings and classmates, why he never feels quite right. He doesn’t know that it’s intanda bwanga, HIV, AIDS or any other thing. I expect he just wants to feel healthy, play football and score a ‘gooooool’. Hopefully he’ll be able to do just that, and soon. As for his new brother or sister, due on 23rd May, Christina and MSF are working together to ensure that he or she will not have to consider such grown-up questions until much, much later in life.

Posted in Field Coordinator, HIV/AIDS, Zambia | 6 Comments

Christina

I will call her Christina. We are almost the same age – she’s 31 and I’m 32. Beyond that, we don’t have much in common. Christina completed 7 years of schooling and is now a married woman with three children and another on the way; her family grows cassava, beans and groundnuts and rears chickens. Occasionally there is surplus to sell, otherwise the family survives at subsistence level. I have a Masters degree and am single and childless. I quite like cooking, but if I had to grow my own food I would definitely be in trouble. This is my fourth mission with MSF in as many years.

I meet Christina for the first time on Wednesday 2nd March, at the rural health centre in Ipusukilo, Luwingu District, northern Zambia. She has come on foot about 1.5 kilometres for her first antenatal consultation, six months into her pregnancy. The distance she has travelled is undoubtedly small compared to many of the other women who crowd the benches, waiting to be seen. Christina is an attractive woman, with a well-proportioned figure; she is formally dressed in a matching skirt and blouse of embroidered batik material in rust orange and purple brown. Her shoes are black and sensible.

On arrival at the health centre, Christina sits alongside the other antenatal mothers and listens to a health talk delivered by one of MSF’s counsellors, Legzai. Addressing the women in Bemba, the most commonly spoken language in this region of Zambia, Legzai explains what they should expect of the day, telling them about the different people who will consult them, and describing the tests that will be performed, including HIV. He tells the women that they have the option to ‘opt out’ of the HIV test if they wish, however I later learn that very few women do so. Unfortunately, this is not because the women understand that in this era of treatment, HIV is no longer a death sentence. It is rather that knowledge around HIV/AIDS in this region of Zambia is so limited that testing positive does not carry with it the same associations as it so often does in other parts of the country – notably fear and stigma. In a country with an estimated 15% HIV prevalence amongst the adult population, it is surprising that in any part of the country there can still be ignorance about an illness that Unicef estimates has left 20% of children without one or more parents. However, in just three weeks in Luwingu District, I have heard time and again that women here who learn of a positive HIV status react with what appears to amount to nonchalance.

This is partly due to a comparatively low HIV prevalence in this region of Zambia. Women of childbearing age in Luwingu District have an estimated prevalence of 7%. Living in sparsely populated rural areas means that while 7% is by no means low, the impact of illness and death may not be as visible as in tightly packed urban spaces. Furthermore, there is a chronic lack of qualified medical staff in the rural health centres and health posts that are scattered across Luwingu District, meaning that the population is understandably not in the habit of visiting them. Therefore when people get sick or die, it is unlikely that they or their families know which illness has afflicted them.

MSF is trying to address the poor health indicators in Luwingu District in several ways, with a specific focus on reducing maternal and neonatal mortality, including reducing HIV transmission from mother to child. Which brings me back to Christina. After listening to the health talk, Christina undergoes the various lab tests. It is at this point that Dr Jeanie Yoon, an American Doctor on her first mission with MSF, approaches me. We had been discussing the previous evening how it would be interesting for me to follow an HIV positive pregnant woman through MSF’s PMTCT (prevention of mother to child transmission) programme, and to write about her experience and hopefully the successful outcome for her baby. Christina’s HIV test has come back positive, and Jeanie asks if I want to meet her.

First of all I consult David Mapulanga, a ‘Lay Counsellor’, who will be the one to talk through the results with Christina. MSF sponsored David through a short training in basic counselling skills in 2010, and now gives him a monthly incentive (approximately 25 Euros) to assist Legzai on the days when MSF comes to Ipusukilo. David comes from the community himself, so he knows many of the women who attend the health centre (including Christina), however he is well-versed on the importance of respecting clients’ confidentiality. When he understands my intentions, David asks Christina if she would mind me joining their counselling session, and she tells him that she doesn’t. I have never sat in a room with someone who is learning that they are HIV positive before, and I imagine how I would feel if it were me. I know that the news would be a devastating blow both to me and my family and friends back home. I know that I would self-stigmatize and that I would be stigmatized by others, who would make assumptions about my private life and through ignorance may even be afraid to touch or hug me. Thinking these things, and sitting across the room from Christina, I want to walk over and hold her hand or hug her. However I decide against it, she doesn’t even know me yet; I hope instead that over the coming weeks and months she will learn to trust me.

Christina's counsellor, David

Christina's counsellor, David

Christina accepts the news quietly and without shedding a tear. I cannot follow the conversation, which is in Bemba, however David does tell me that she is worried about her 3-year old, who is not in good health. David tells her it is important that she brings him to her next consultation, which will be in two weeks, so that he can also be tested. When David asks about her husband, she explains that he is in the Copperbelt Province, that he went there for a visit, and she had been expecting him back in December. She says this matter-of-factly, as if December was just yesterday.

When David has finished the counselling session, he accompanies Christina to see Jeanie, and translates the consultation. Jeanie explains that it’s possible to be HIV positive and to feel fine, but eventually the body weakens and becomes vulnerable to infections, and that’s when it’s necessary to start treatment. Christina has her head down and only nods to indicate that she understands the translation, while fiddling with the handles of her handbag, the colours of which match her outfit. Jeanie goes on to explain that babies born with HIV will normally die before they are two years old, however fortunately there is treatment available which can significantly reduce the likelihood of the baby contracting HIV in the first place. She says that to find out which treatment Christina should take, she must send a sample of her blood to the laboratory and wait two weeks. Jeanie then asks Christina to think carefully about who could assist her as a ‘treatment supporter’ – perhaps her husband or her mother? She says if possible, Christina should try to identify a treatment supporter and this person should accompany her on her next visit. Crucially, Jeanie also asks precise directions to Christina’s house, in case she doesn’t turn up for her next appointment. This is where David’s local knowledge comes in very handy – since he already knows Christina, he also knows where she lives; in all the health facilities where we are currently working in Luwingu, we are using Lay Counsellors such as David to carry out ‘defaulter tracing’, to visit the homes of women who have missed an appointment and to convince them to come back.

Finally Jeanie asks how Christina is feeling, and if she has lost any weight. Christina says that sometimes she coughs and feels feverish, however she doesn’t think she has lost weight. Before leaving, Christina has an antenatal consultation with the MSF Midwife on duty, Zodwa. Zodwa registers her, takes a basic history and performs a palpation (to gauge the gestational age and hear the foetal heartbeat). Christina is clear that she has been fully vaccinated against Tetanus. Zodwa gives her ferrous sulphate with iron to elevate her haemoglobin, a deworming tablet which Christina must chew there and then, Fansidar to prevent Malaria, a mosquito net and multivitamins. She is now free to go, and we all hope that we will see her again in two weeks’ time.

Posted in Field Coordinator, HIV/AIDS, Zambia | 6 Comments

New blog: Following Christina

Following a period spent in the UK and on mission with Merlin in Haiti after her MSF mission to Liberia, Emily is back working for MSF in Zambia. Her new blog Following Christina follows the progress of Christina, an MSF patient who has tested positive for HIV.

Emily is working for MSF as a field coordinator.

Posted in Field Coordinator, HIV/AIDS, Zambia | 1 Comment

Leaving Liberia

I left Liberia in time to reunite with my family in England for Christmas. After 11 months working at Benson, saying goodbye to my colleagues and friends was predictably difficult. Through email and social networking, however, it will be a lot easier to stay in touch with them than it would have been a few years ago. This is a comfort to me.

I wanted to write so much more on this blog, there are so many stories left untold. One of the most important stories which I neglected to tell is that in 2010, MSF will be handing over the medical services of Benson Hospital to the Liberian Ministry of Health. Liberia is now considered a stable country with a democratically elected government; dozens of international organisations now operate here and the government has officially committed to suspending patient fees in its health facilities. While the country still has a long way to go, Liberia has achieved a few notable improvements in health indicators. MSF is making every effort to ensure that the Liberian Ministry of Health will be in a position to fill the gap left by the closure of MSF facilities. We are currently renovating a structure in Monrovia, not far from Benson Hospital, where Benson’s medical activities will shortly be transferred and then handed over to the responsibility of the Ministry of Health. The staff of Benson Hospital will also be signed off the MSF payroll and, if they wish, reassigned to the Ministry of Health.

2010, therefore, will be a watershed year for MSF in Liberia. Not only will it mark 20 years since MSF first entered the country, it will also be the year that we close our remaining hospitals – a move which has been planned since 2007. Across town from Benson Hospital, MSF is closing our only other remaining hospital in Liberia – Island Hospital, a paediatric hospital of 186 beds. The patients will be partially absorbed by an existing Ministry of Health facility, which MSF has been supporting to expand.

I am finally writing this last entry sitting in the dining room of a hotel in Port-au-Prince, Haïti. Outside the evening is balmy and a rainstorm that was threatening seems to have passed by. As I’m sleeping in a tent in the backyard of the hotel, this is a relief. While MSF starts to wind down in Liberia, here in Haïti the needs are complex and overwhelming. MSF was here before the 12th January earthquake and will remain here for many years to come, providing a vast array of medical interventions to a population that has been devastated both physically and psychologically. This time around I am working for Merlin [www.merlin.org.uk], in a similar capacity to my position as FieldCo at Benson. Only this time the hospital is constructed from tents on some tennis courts, and the surgery is orthopaedic and plastic reconstructive.

Thank you for sharing your thoughts and ideas with me over the last year or so. I will likely be keeping a similar blog about my time in Haïti with Merlin, so please look for me there if you are interested. Meanwhile, I will keep in close contact with my MSF Family, and I encourage you to do the same. :)

Me with Benson patients

Me with Benson patients

Posted in Field Coordinator, Liberia, Maternal/Child Health | Comments Off

Rebecca

‘When Rebecca started improving, I felt so, so happy. For at least 5 or 6 days, I had been very anxious about her. Her mother would always take my hand and thank me every time we came out of the operating theatre (OT), but inside I was afraid that she might die’ Dr Maria Laura Vasilchin, Gynaecologist, Benson Hospital

The photo above shows Rebecca seated between her mother and Maria Laura on 25th September, the day she was finally discharged from Benson.

The photo above shows Rebecca seated between her mother and Maria Laura on 25th September, the day she was finally discharged from Benson.

Dressed simply in a pink t-shirt tucked into a traditional ‘lappa’ tied securely around her waist, Rebecca tells me in a quiet voice that she cannot remember clearly the journey from her home in Kakata (a town approximately 50 km from Monrovia) to Benson Hospital on 18th August. She remembers the car travelling very fast, and she remembers the bumps in the road, which exacerbated her already severe abdominal pain. She was in labour with her fifth child; however the experience was nothing like her other labours, which had been trouble-free and without any medication. She delivered her first two sons, now aged 14 and 10, in the bush during the war; her daughters, aged 8 and 2, were both born at her home in Kakata, with a community midwife in attendance. During her fifth pregnancy, Rebecca had visited her local clinic for antenatal care (ANC), and she also planned to deliver there. When the day came, however, the clinic turned her away saying they could not manage her condition. Some members of her community knew about Benson Hospital for women having difficulty ‘borning’, so her family loaded her into a car belonging to a community member and covered the cost of fuel required for 45 minute trip to Monrovia.

The midwives at Benson attempted to deliver the child in our maternity; however when they realized that the feet were presenting first, Rebecca was rushed to the OT for a Caesarean section. She remembers climbing onto the bed in the OT, and later recovering consciousness in the recovery room while a nurse waved a hand in front of her face and asked her ‘You see me? You see me?’.

Olivia Stewart, a Liberian Nurse at Benson Hospital since 2003, explains that if a newborn baby does not survive, one of the medical staff usually informs a relative, who will then inform the mother. Rebecca didn’t need anyone to tell her, she figured it out for herself. When she was transferred to our Gynaecology ward, she saw other women in the ward breastfeeding their newborns, or sleeping beside small packages wrapped in brightly coloured lappa. Nobody was handing her an infant to suckle, there was no brightly coloured package on her bed. Rebecca’s baby died due to foetal distress, a condition where the baby’s heart rate increases or decreases dramatically due to lack of oxygen. If Rebecca had been in a country with better antenatal services at clinic level, in a country with tarmac roads, with ambulances, with more surgeons, more free hospitals, then maybe, just maybe, her fifth child would be alive today. As the fourth child and third daughter in a family of five children, I feel compelled to ask Rebecca if she knew the gender of her fifth child. ‘De white woman told me na girl child’, she says, ‘she was sooo big’, she adds with a hint of pride.

Unbeknownst to her, Rebecca would stay at Benson a further 5 weeks following the loss of her infant. In the days following her Caesarean section, she developed a high fever, and the site where she was operated on started to leak, indicating an infection. When Maria Laura performed a laparotomy (in plain English an abdominal exploration), she found that Rebecca had developed a huge infection of the uterus; she had no choice but to carry out a hysterectomy. When her fever still persisted, Maria Laura opened her up one last time and cleaned her abdominal cavity. Rebecca says she cried each time she was told she couldn’t eat after midnight, knowing that the next day she would be wheeled through the dreaded swing doors of the OT.

Rebecca speaks candidly, she understands that her uterus is ‘spoiled’, but she thanks God first, and Benson second, for her life. Her smile and composure on the day of her departure from Benson belie the physical and emotional pain the she has endured here, however she vows to return. She wants to see Maria Laura again before she ends her mission and returns to Argentina, and she wants to thank everyone at Benson again for restoring her health. But right now, all she wants to do is go home to her husband and family.

Posted in Field Coordinator, Liberia, Maternal/Child Health | 1 Comment

Three is Company

“I were happy”, says Esther, 25, when I asked her how she felt when she gave birth to triplets instead of the expected single baby. Esther and her husband, Wilson, 23, call the multiple births on 3rd March “a gift from God”. They named the girls Nancy, Rita and Ellen. Nancy after the traditional midwife in their community who delivered the babies at their house, Rita after Wilson’s sister with the same name, and Ellen after Liberia’s President – Ellen Johnson Sirleaf.

Emily Bell

Esther, Wilson and Angie (expat Nurse) with the triplets, outside their house in Lakpazee, Monrovia. | Photo: Emily Bell

11 days after the triplets were born, Wilson and Esther took them to Benson Hospital because “they went off…they were getting darker”. After a helpful consultation with the Paediatrician who took care of the triplets, I learn that the triplets were suffering from neonatal sepsis and malnutrition; they were lethargic, feverish and not feeding well. They weighed 1 kg (2.2 pounds) a piece and Esther was struggling to satisfy their hunger with breast milk alone. When they
arrived, they were kept warm and closely monitored in our intensive care unit (ICU), and fed on a diet of antibiotics, breast milk and infant formula through a syringe. Mum was provided with three meals a day by Benson’s kitchen (porridge and bulghar wheat), and allowed to catch up on much needed sleep. When the babies were stronger, they were moved upstairs to the Paediatric Ward, and on 8th May – each weighing 2.5 kg (5.5 pounds) – they were finally allowed to go home.

I first met Wilson when the triplets were still admitted at Benson. With an open, innocent face, and an infectious smile, he approached me and asked if MSF could continue to help the family, even after the triplets were discharged. They already had an 18-month old to take care of and, like many of the families who bring their children to Benson, they were desperately struggling to make ends meet. Unable to find any other organization that could provide them with assistance, and in view of the exceptional circumstances, we agreed to provide them with formula milk until the triplets are nine months old (while at Benson, Esther had been given proper instructions on formula milk use while continuing to breast feed).

Last week I visited Wilson, Esther, the triplets and their extended family at their home in Lakpazee, not too far from where I live in Monrovia. Approaching their community at dusk, I pass the ubiquitous plywood shacks painted in bright colours, home to ‘entertainment centres’ (if you want to see a Nigerian movie on a television), barber services or small shops selling daily essentials such as eggs, sugar, soap and telephone scratch cards. At this time of the evening, the average Monrovian is in a hurry to complete the day’s last task before darkness descends. Young girls and boys balance buckets of water precariously on their head and steady themselves before beginning the walk home. Barefoot boys who have escaped their chores play impromptu football games with a ball if there is one, if not then a handmade equivalent. Women and girls sit in front of their houses and take turns to fix each other’s hair – the victim usually looking bored and uncomfortable, not to mention faintly ridiculous if the job is only half-finished – one side of her head displaying neat, orderly cornrows, and the other a wild, untamed afro.

Wilson tells me that he dreams of living in a ‘professional house’, meaning one made from concrete. The house he lives in currently is cobbled together from traditional matting and corrugated zinc sheeting – the latter a popular low-cost building material in urban Africa, and a deafening one in a country with rainfall as heavy as Liberia’s. In one of only two rooms in the house, Wilson sleeps on the floor with his wife, the triplets, and no less than four boys who are all somehow related to Wilson. There is barely room to move without stepping on the sleeping area, which is covered by a giant mosquito net. Rita, Wilson’s sister, sleeps with her husband in the small room opposite.

Cooking, eating, washing and socializing all happen outside. Rice and gari (fermented cassava) are prepared on a ‘coal pot’ at ground level. The community water pump is conveniently located across the street from the family’s house. In the midst of the rainy season, water supply is rarely a problem, although the quality occasionally results in a ‘running’ stomach. In the height of the dry season, however, families like Wilson’s are forced to buy drinking water – sold at 50 Liberian Dollars or ‘Liberties’ (70 US cents) for 5 gallons. The ‘shower’ that Esther emerges from as we arrive at the house is a patch of ground barely enclosed by some zinc sheeting; this same patch of ground serves as a toilet; ‘pupu’ is put in a plastic bag and thrown over the fence.

Esther wishes for a generator, and as we sit on the small porch at the front of her house with the natural light rapidly fading, it’s easy to understand why. It’s only 7 pm and the triplets are all wide awake, although I seem to be more worried about this fact than Esther, who exudes serenity at all times. Wilson rummages around to find the household’s only torch, which doesn’t function with his first attempt. He takes the batteries out, rubs them on his trousers and gives them a blow, which seems to do the trick. The only income the household has comes from selling drinking water for 5 Liberties (7 US cents) per sachet, and coal at 10 Liberties per bag; they are lucky to have 15 customers per day which is a maximum of 150 Liberties, equivalent to about 2 US dollars. 2 USD for 9 people for one day! Even purchasing candles is beyond the means of Wilson and Esther, a generator is but a pipe dream. I think to myself that I must email my friend Charlie, who is coming to visit me in September. If she could bring Esther a head torch, that might at least make the nights a little brighter for her.

This post is dedicated to Professor David Morley, who died on 2nd July 2009, aged 86. Morley was a Paediatrician and an Emeritus Professor of Tropical Child Health, and he inspired my interest in health in developing countries when I was studying English Literature & French at the University of Manchester over ten years ago. He supported and encouraged me to develop my career in this field, and it is largely thanks to his mentorship that I am working for MSF today. Before my blog went live, I emailed him the first two posts in order to have his valued opinion. Fortunately for me, he approved, and one of his comments was: ‘Yes I think you should (go ahead)…we do not hear enough about people’s ‘pupu problems’…please enroll me’. This very down to earth and no nonsense statement was typical of a man who dedicated his life’s work to improving the health conditions in underprivileged communities. His obituary can be read free of charge on The Lancet website here:

http://www.thelancet.com/journals/lancet/article/PIIS0140673609614410/fulltext?rss=yes

And an article about him in his local newspaper:

http://www.hertsad.co.uk/search/story.aspx?brand=HADOnline&category=News_Harpenden&itemid=WEED09%20Jul%202009%2016:34:18:990&tBrand=HADOnline&tCategory=search

Posted in Field Coordinator, Liberia, Maternal/Child Health | 4 Comments

Boss Lady (aka the FieldCo)

Mauricio Aragno.

Boss Lady + expats (sometimes mistakenly referred to as 'experts'). Photo: Mauricio Aragno.

First of all, there are no fields involved in my work. Not of the grassy variety anyway. ‘The Field’ is an interesting term that is bandied around a great deal in development and humanitarian circles, and it is interpreted differently depending on where you are when you say it*. Benson Hospital, despite being in the capital city, is considered to be The Field. At the project level, we have our own offices, our own vehicles, expat residence etc. MSF-Spain also has a coordination office in central Monrovia – their job is to support the teams in The Field, including Benson.

Sometimes, to avoid confusion, I introduce myself as a Hospital Director rather than a Field Coordinator. I always feel quite strange saying this. How can I be a Hospital Director? Most of my hospital experience before coming to Liberia was accompanying my dad to the hospital where he works every Christmas Day when I was a child. He used to wear a Father Christmas hat and carve turkey for those unlucky enough to be spending the festive season in the Royal Berks, Reading. My brothers and sisters and I, usually accompanied by a pet or two, used to pass around the Christmas dinner to the patients, and then wait angelically to be given stockings full of chocolate by the nurses (the real reason we were there, obviously).

Yet here I am, quite a few Christmases (and a LOT of chocolate) later, able to call myself a Hospital Director without being laughed at. I have my own office, a business card, and people call me ‘boss lady’. But, you’re probably wondering, what do I actually do?

Fortunately for me, my job is quite varied. I will describe some of the things I did last week and some of the things on my ‘to do’ list for the coming week.

Tuesday 7th July: on the day that Michael Jackson was buried, I spent the morning with a film crew from Britain who are currently in Liberia making a documentary (for Channel 4′s ‘Unreported World’ series) about sexual violence against children. I am responsible for communication and representation for the Benson Hospital project, and was asked to connect the filmmakers with relevant local actors. I accompanied them to meet the staff at the THINK clinic for sexual violence, where they interviewed some victims – all young teenage girls. THINK is a Liberian organization that took over this service from Benson Hospital one year ago. They are one of the only organizations in Liberia providing comprehensive care to rape victims – including ‘PEP’ (post-exposure prophylaxis which can prevent the victim from contracting HIV), emergency contraception and counselling. We continue to provide them with their medical and non-medical supplies every month in order to keep the programme going.

Thursday 9th July: One of my most time-consuming responsibilities as a FieldCo is human resource management. As I mentioned in my first posting, we have over 200 Liberian staff at Benson and currently 6 expatriates. For each ward and category of staff there is a Supervisor, for example we have a Physician Assistant Supervisor (18 PAs), a Cleaner Supervisor (19 cleaners), a Supervisor for the Operating Theatre, for the Laboratory, etc. Last Thursday, I had several meetings relating to HRM. I held a meeting with all of the Supervisors (16 in total) to brief them about the new division of responsibilities in light of 2 expatriates recently leaving whose positions will not be replaced. There was what we call a ‘disciplinary action meeting’ involving a Nurse who had been spotted far from the hospital when she was on fact on duty… Finally, a meeting was held with our 26 Watchmen to discuss some recent breaches of security at the expatriate residence and how these can be prevented in future.

Sunday 12th July: Day of rest. I made a cake and played ping-pong with the Watchmen at our compound. In the afternoon I went to downtown Monrovia to find Dennis – a 16-year old lad who suffered from polio as a child and is wheelchair bound as a result. Dennis begs every Saturday night outside a bar that is popular with expats, and in June I lugged a set of crutches from a wedding in the Cotswolds all the way back to Liberia to give to him (very long story). Afterwards, I spent $16 on lunch with 2 British friends at a nearby posh hotel, which is probably more than Dennis earns begging in a month. Did that make me feel terrible? No. Is that wrong? I don’t know. But I never claimed to be a saint and I have always maintained that being an expat is a pretty odd kind of existence.

Emily Bell.

Dennis with his crutches. Photo: Emily Bell.

On my to do list for the coming week, let me see…

  1. (planning and reporting): write the situation report (in MSF lingo ‘SitRep’) for June!
  2. (project implementation): I need to write to JFK Memorial Hospital (Liberia’s main referral hospital) to inform them that from now on we will not be admitting ‘caustic soda patients’. These are normally young children who have ingested caustic soda (mistaking it for water), which causes their oesophagus to constrict, making it extremely difficult for them to swallow. To help them requires a surgical intervention known as oesophageal dilation, which widens their oesophagus. Depending on the severity of the case they may require several dilations before they can swallow normally again – this can be done here in Liberia but even this is often only a temporary relief. Surgery to provide these patients with a more hopeful future is not available in this country for want of a Paediatric Anaesthetist. Therefore we have taken the painful decision that from now on we will not accept these patients in order to liberate beds for children who have more chance of survival. I can and will write a whole separate posting about these patients if the interest is there (let me know).
  3. (HRM): I will spend a couple of hours doing a mid-term evaluation with our long-suffering Paediatrician from Germany, who is now over half way through her first mission with MSF. The expat Paediatrician at Benson never has an easy time of it, reading point 2 above you will understand why.
  4. (financial management): I will discuss with Victor, our Field Finance / Admin Assistant, a new method of paying salaries at project level (details top secret), which I’m pretty sure will go down like a lead balloon…(it involves banks, which are generally pretty unpopular in Liberia).
  5. (establish / maintain relations with local authorities): I will attend the monthly Montserrado County Health Team meeting on Thursday, to receive an update on the Ministry of Health upcoming plans and activities, and those of other NGOs.
  6. Finish this blog posting…

*If you’re in the European headquarters of an international NGO and someone says they are going to visit The Field, then it is well understood that they are heading to a country where that NGO is operating – let’s say Chad. Once in the capital, N’Djamena, those left behind in Europe will consider that this person is squarely in The Field. However, if the NGO in question is only running ‘coordination’-type activities in N’Djamena (for example, liasing with Chadian authorities, receiving supplies etc.), and the activities which benefit the population are happening elsewhere in the country, then N’Djamena is definitely not The Field. In this case, those in N’Djamena will consider those in the project sites to be in The Field. Nor does it end there; if the project has some remote activities, in MSF’s case mobile clinics, then only when you have driven 3 hours on terrible roads away from the project base and set up your clinic for the day in a shady area can you truly say you are In The Field (and probably, by this point, you actually are standing in a field).

Posted in Field Coordinator, Liberia, Maternal/Child Health | 4 Comments