Welcome to Bravo Hotel: Stories from Monrovia

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

‘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.

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 18^th 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.

“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.

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

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.

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).

I am swimming towards the Heart of the Matter. The water is cool, deep and impossibly blue. Watching me from the shore is Catherine, a 26-year old British NGO worker, and three Sierra Leonean teenagers, including a 15-year old amputee called David.* Tomorrow, Sierra Leone celebrates 48 years of independence; tonight Freetown will come alive with street parades and festivities. But for now, I’m focused on the Heart of the Matter, the boat that will transport this motley crew from Lakka beach to Banana Island.

I’m back in Sierra Leone, this time on holiday. I knew Abdul*, 14, from when I was last here. In those days, he was a bright-eyed 12-year old who I used to quiz on the capital cities of the world whenever I met him at Lakka. These days, he’s still bright-eyed, but perhaps more interested in dance moves and girls than geography. I had never set eyes on David during the 18 months I worked in Freetown in 2005-06. I can say that with certainty because child amputees tend to stick in one’s head. I remember the teenager who used to beg at the helipad in Aberdeen who was missing both his arms above the elbow, and a small boy at River Number 2 beach with a ‘chopped’ arm flopping uselessly at his side. But most of all I remember one afternoon in Makeni. Wandering aimlessly around an NGO compound talking to a family member in England on the telephone, I heard a persistent tapping at the steel gates. I continued talking but went over and slid open the little window in the gate that allowed you to inspect visitors. At eye level I could see nobody, but looking down I saw a young girl, no older than 10, peering up at me. It took me a few seconds to register that both of her arms were missing, both cleanly sliced off just below the shoulder – like the incomplete mannequins you sometimes see in department stores, modeling some item of clothing which does not require arms or hands. I never found out this girl’s story. I’m pretty sure I turned on my heel and continued circling the compound, not wanting to tell the person on the other end of the telephone what I had just seen, and not wanting to think about it too much myself either.

I learned David’s story, however, within minutes of setting eyes on him. Working in Sierra Leone, Chad and now Liberia, I have lost my original shyness in talking to people who have been affected by war. In my experience, most want to share their story. If they don’t, then they will tell you, and of course that’s fine too. When I asked David if he lost his leg during the war, he replied straight away ‘yes and they killed my parents too’. On the same day, aged just three. A three-year old child, to lose both parents and a limb to a band of marauding rebels, some of whom were probably the same age as David is today, such is the stuff that nightmares are made of. I think of my identical twin nephews who recently bobbed around in front of a web camera in Cornwall telling me ‘we’re fooooourrrr today Emmy we’re fooooourrrr…’

Back in Monrovia, a new expatriate Surgeon has joined our team. Henrike Meyer has worked in Sierra Leone for MSF on 3 different occasions, in 1998, 1999 and 2003. In 1998, her mission ran from early April until late June, during which time she says the team at Connaught Hospital in Freetown treated around 200 victims of amputation / attempted amputation. She remembers in particular a mother of 7 children, the youngest of whom were twins, whose left hand was barely attached and required amputation. The woman had been distraught at the prospect of caring for her children with only one hand. One year later, Henrike encountered the same woman at an amputee camp in western Freetown, and ten years on she still cherishes the moment when the woman ran to hug her and to tell her that she was well, that she was managing despite losing her hand.

On our journey, the boat owner tells me that he had attempted to read Graham Greene’s 1948 novel ‘The Heart of the Matter’, a bleak story of Catholic guilt set in Sierra Leone during World War II, which I struggled through in my first weeks in the country. But it hadn’t grabbed him and he never finished it, but he liked the name and used it for his boat. I smile to myself, tell him that he was sensible to do so, and then settle my gaze on Sierra Leone’s coastline from paradise. That this beautiful, magical land became the stage for such acts of cruelty is impossible to reconcile, but it is to the heart of this matter that most Sierra Leoneans are set on journeying, to ensure that it never happens again.

*names changed

Photo: Emily Bell

I feel it is about time to give a better introduction to Benson Hospital, a little bit of history and a kind of virtual tour. This could be an epic journey, but to prevent you from getting lost I will attempt to present Benson in a blog-sized portion. Therefore, below I depict Benson in a skeletal form, which I hope will prove useful in setting the scene for my future postings. I welcome questions & comments, in fact I positively encourage them…

Benson Hospital (‘Bravo Hotel’ in radio speak) is so-called because Dr Benson, a Liberian physician, used to run a gynaecological clinic in what is now our main hospital building. In 2003, MSF-Switzerland started to rent the building from Dr Benson, running a general hospital until 2005 when they handed over operations to their sister organization, MSF-Spain, who have run the hospital ever since. At that point, it was decided that Benson would focus on services for women and children, who were identified as the most vulnerable groups in Paynesville – a poor area in the east of Monrovia, and since the war years home to a large displaced population.

Photo: Naoya Iwasaki. Benson main building

Today, Benson Hospital comprises not only the original compound owned by Dr Benson, but also the adjoining compound and 2 additional compounds on the other side of the dusty road. The 3-storey main building, painted two-tone green (which reminds me of school), is a landmark in Paynesville – where even 2-storey buildings are a rare sight. Walk up the ramp into the main entrance, and inside the green walls you will find a hive of activity 24 hours a day, seven days a week. On the ground floor there are two operating theatres, an intensive care unit with space for 16 paediatric patients and a gynaecological ward with 27 beds. The patients admitted to the latter include women recovering from miscarriages & unsafe abortions, as well as operations such as caesarean sections & hysterectomies. Tucked discreetly in a corner of the indoor/outdoor maze of the ground floor is the morgue. Climb the stairs and there are a further 44 paediatric beds on the first floor, and another 10 on the second floor. The hospital offices, including my own, are also on this floor.

The adjoining compound is referred to as the ‘log compound’, however also on this site there is the emergency room and the laboratory – including what is apparently the largest blood reserve in Liberia (171 transfusions in March alone). Next to the lab, there is a small, hot kitchen where the food is prepared for the patients (porridge for breakfast and dinner, bulgur wheat for lunch), and an outdoor laundry area for caretakers to wash the clothes of the admitted patients (each admitted patient must be accompanied by a caretaker). The ‘log’ part of the ‘log compound’ includes a radio room, the waste management unit, a warehouse, parking for our 6 vehicles, a mechanic’s pit, fuel store and, and, and…

Cross the dusty road, and the final two compounds (phew!) house Benson’s central pharmacy and maternity unit (a further 12 beds). Here ends your virtual tour.

I don’t know how obvious it was where you were, but if you were in Monrovia yesterday and failed to notice it was International Women’s Day then I would say you are seriously unobservant. To mark the occasion, Monrovia has been the host city for an international women’s ‘colloquium’ (personally this word only entered my vocabulary about 2 weeks ago) over the past few days, which brought together eminent women from all over the world to discuss issues around women, including their role as leaders and arbiters of peace.

The latter two topics could not be more relevant than in Liberia, the first country in Africa to have a female elected head of state and one where women played a crucial role in bringing an end to a long and bloody civil war. I have just returned from the national stadium where I attended one of the closing events of the colloquium – an open air screening of ‘Pray the Devil back to Hell’, a film that chronicles the remarkable activism of Liberian women during the war. Through television footage from the era and interviews with key female activists, the film patches together the events that led to eventual peace in Liberia. An army of women in white t-shirts silently and not so silently protested their way through the war, confronting Charles Taylor and the warlords and even following them to peace talks in Ghana – where at one point they barricaded the participants in their meeting room, so frustrated were they at the lack of decision-making that was taking place. In the end it paid off. Taylor went into exile in 2003 and a transitional government took over until elections were held in 2005. In the words of one activist, the election of a woman – ‘sista Ellen’ (referring to President Ellen Johnson Sirleaf) – was the icing on the cake for the women’s movement.

I had entered the stadium in a last minute rush and on the phone to my own sister in England, and was more concerned about getting a good seat near the front than paying much attention to what was going on around me. When I stood up at the end of the film and as the lights came up, I turned around and realized that the majority of the people at the screening were the ladies in white t-shirts – they were wearing them as proudly today as they did back in 2003 when the UN peacekeepers finally entered Liberia. I was happy that I could show them my own t-shirt, which reads ‘Liberian Women are Something-O!’, which generated much laughter and photo taking (Liberians like to add ‘o’ to the end of most sentences).

Photo: Emily Bell.

The patients and staff at Benson Hospital also had their share of VIW (Very Important Woman) action over the weekend, yesterday we were visited in the morning by the Spanish Vice-President, Maria Teresa Fernández de la Vega and in the afternoon by the European Commissioner for Health, Androulla Vassiliou. Emmanuel, the protagonist in my last entry, won many hearts by dressing up smartly and presenting the VIWs with flowers, and has even earned himself a picture on the web: http://www.estrelladigital.es/ED/diario/100705.asp

When I was living in Freetown, one day one of the watchmen came to me, exasperated, telling me that his son had had an accident and was in a nearby hospital (not an MSF facility). Sahr, aged 15 months, had stumbled into a pot full of boiling water that was bubbling away on a charcoal stove on the floor of his mother’s kitchen. It was the first time I had seen a black person with severe burns. I remember thinking how one of his little hands looked like it had been dipped in dark chocolate, because only the tips of his fingers were still brown – the rest of the hand and arm was raw, pink flesh, as was most of one side of his body. Sahr spent weeks in hospital, when he was discharged I drove the family back to their house, armed with bandages, lotions & instructions on how to take care of him. A few weeks later, Sahr died. The news came as a complete shock to me because I thought he was over the worst of it. To this day, I don’t know why he wasn’t taken back to the hospital when his condition started to deteriorate.

At that time I thought that this was a freak accident, little did I know. In the paediatric unit at Benson Hospital, we have little mummies wandering the corridors every day of the year. Their story is always the same: they were scalded by hot water. Often the victims are toddlers – practising their first steps and curious at the same time – a worrisome combination in all societies. In Africa, where food is commonly prepared on fires at ground level, it is unsurprising that this is such a frequent injury.

Photo: Emily Bell, MSF | Emmanuel

Emmanuel, pictured above, is four. He was admitted to Benson on 29th January with 2nd degree burns on the left side of his body. On that day, he had been playing with his homemade toy truck (the kind often seen in Africa, ingeniously crafted together using scrap metal, wire and bottle tops for wheels) – chasing around his house and compound using a stick to push it forward. At one point the car flew forward further than normal and Emmanuel & his friend sprinted after it. Emmanuel reached it first but his friend collided into him and sent him flying into a pot of boiling water that was on a coal fire in the hall. Emmanuel’s mother was not in Monrovia at the time, his aunt was taking care of him, but she was not at home when the accident happened. A local pastor took Emmanuel to Benson Hospital from his home in ZayZay Community, fortunately not too far from us. Emmanuel remembers a neighbour removing the clothes that were stuck to his body and the painful motorbike journey.

Emmanuel has now been in the hospital over 3 weeks. He’s become a familiar face, as he likes to lounge around the reception area of the hospital – a breezier choice than the crowded room he shares with 2 other burns patients and their caretakers. He knows my name, which, like most Liberians, he pronounces ‘Emly’, and we often have a little chat. One morning last week I went to watch him have his bandages changed, which for him is a traumatic daily ritual. He told me that the part he dislikes most about the dressing is the injection he receives, this being Ketamine for pain management. The fact that this is the worst part for him must indicate that it at least works – if he was fully conscious during the change of dressings he would surely be in excruciating pain. Apart from the injections though, Emmanuel likes the hospital, in his own words – ‘Benson mek ma sore to die’ (loosely translated: ‘Benson is making my sores die’).

From our expat house in Congo Town, eastern Monrovia, it’s possible to see the sea from the first floor terrace, and to hear the waves crashing on the sand. The beach can be accessed on foot in a couple of minutes, and according to our security rules we are allowed to reach as far as the Chinese Embassy – a large, modern complex which looks incongruous in the surroundings and at night is lit up like a football stadium. This evening I jogged to the Embassy & back with 2 colleagues. It was a beautiful evening and the beach was flat and smooth which was perfect for the occasion. On nearing the Embassy, I saw a man sitting in a squatting position in the sand. I blinked twice: was he defecating? When I returned in the other direction, I discreetly had another look. He was definitely defecating, and he didn’t seem to mind that people could see him. A colleague had warned me that the beach near our house wasn’t clean, but I thought he was exaggerating when he said that people actually defecate on the beach. Clearly he wasn’t. Despite this, I was so hot at the end of my jog that I still ran straight into the sea and splashed around for a few minutes. On emerging, I saw not one but two more people defecating on the sand. One of them was a young lad in his early 20s who had taken a quick break from a game of football which was engaging around ten Liberians and now also my colleague Oriol. He was beaming at me, so I couldn’t resist.
 
‘Why do you make pupu on the beach?’
 
5 minutes and an amusing conversation later, I learnt that people pupu on the beach because the government doesn’t provide any facilities on the beach. The lad, who is currently enrolled at university in Monrovia, knows that defecating on the beach is not nice behaviour, but there are no latrines at the beach, and he had a natural urge, so what else can he do?
 
He has a point, however I don’t think I’ll be joining him next time I need the toilet at the beach.
 
Of course pupu on the beach is nothing. Liberia is recovering from 14 years of civil war, which left a broken society and the country on its knees. My days are full of contrast. One minute I am relishing every moment of being back in west Africa (I spent 18 months in Sierra Leone in 2005-6) – the colours, the music, the natural openness and fun of Liberian people. But the next I feel like pulling my hair out when something happens which makes me wonder how and when Liberian society will manage to rally together and rebuild its land. Children under the age of 10 are regularly brought into MSF facilities in Monrovia for medical attention and counselling after being raped. In my first week we received a 5-year old rape victim, who was so ashamed of what had happened to her that she told the doctor that she had fallen off a seesaw. On Friday, I was alerted that we had an abandoned infant on our hands; a girl aged 1 ½ who was malnourished & suffering from malaria. Her mother had left on Thursday afternoon and had not reappeared. The frightened child started to cry every time someone went near her. The mother reappeared briefly on Sunday, but left again, so when she turned up on Monday I asked to talk to her. She was very young and looked afraid as she explained that she had a small baby from a different father at home. The father of the second child didn’t care for the first child; therefore it was difficult for her to stay at the hospital. We asked her to bring her baby to the hospital so she could be with both of her children, she agreed but it’s very possible she will not return. Abandoned babies and children are by no means common, but they are common enough that we have a procedure in place for dealing with these types of situations.
 
The war lives on in the minds of the people, and the impact of the war undoubtedly affects our everyday activities: which patients come, why they come, how they react to new life, death and everything in-between. I know already that my experience in Liberia will be very different to the time I spent in Sierra Leone – Liberia’s neighbour & also a very poor country recovering from a long and brutal conflict. I was not working for MSF in Sierra Leone but a development-oriented organization running projects in agriculture and construction. While the physical scars of the war were visible for all to see, my day-to-day activities and experiences were not a constant reminder of the less tangible consequences – those inherited by the people who experienced a generation of brutality.

My mother has warned me not to become too attached to the children in the paediatric wards at MSF Spain’s Benson Hospital or I will become, in her words, ‘emotionally bankrupt’. I fear she may be right, but it will not be easy. My office for the next 9 months is situated in Benson Hospital, in the same building as the ‘paeds’ wards – so even before I enter my office and switch on my computer I am inevitably distracted by the likes of Fred, pictured below with his 19-year old mother. Fred is malnourished, like many of the children in our hospital, however in order to be admitted into our facility he must have presented with other symptoms – probably malaria. Of the approximately 250 Liberian staff who keeps Benson Hospital operating, I have not yet located the individual who takes care of Fred. When I see him he is not being weighed, poked or prodded, he is simply wobbling around the building on unsteady legs, holding tightly onto his mother’s hand and smiling suspiciously at any white folk who cross his path.

Photo: Emily Bell, MSF | Fred and his mother.

I have just completed my 5th day in Liberia, however as always with MSF I do not feel as if I am in an unfamiliar land surrounded by strangers. Undoubtedly it will sound cheesy, but I feel I have been welcomed back into the home of my second family. Cristina, who I am replacing, left Liberia yesterday and today I made it through my first day on the job as ‘Field Coordinator’ for the MSF Benson Hospital project in Liberia’s capital city, Monrovia. The organigram that Cristina printed for me on my first day fills 3 horizontal A4 pages, and above 6 expatriate and 250 Liberian staff was my name, Emily Bell. Even though I knew that’s why I was here, seeing my name presented in such a way made my heart beat loud and fast. At the end of Day 1, seemingly everyone knew my name already and I was still struggling to remember the names of the expats who I live with, who come from as far a field as Japan, Greece and Argentina and have equally exotic names to match. 4 days later I’m doing somewhat better, however as the saying goes in Liberia, it is definitely ‘no easy’.