To Nimba and back, the first time...

The end of this first week in Liberia has confirmed that my days with the Clinton Foundation will be hugely diverse.

On Thursday morning I met with the Chief Pharmacist at the National Drug Service to discuss data regarding the first line test, Determine. We reviewed a couple key figures before heading to the warehouse to do a second count of the inventory – I was amazed by how helpful in conceptualizing the current supply chain process it was to work in the warehouse and handle the tests. There are so many practical challenges that need to be addressed; many of the HIV tests, for example, are stored in unmarked refrigerators, making it difficult to count the stock with any certainty. Though someone may be keeping track, there needs to be a standardized inventory management system. At about 10 o’clock, as I was finishing taking inventory, I had begun to wrap my head around this new job.

I left from NDS to go to an M&E (Monitoring and Evaluation) workshop at Thinker’s Island, a beach roughly 20 minutes away. The workshop convened various Deputy Managers and Officers of the MoH, as well as facilitators from CHAI, UNDP, and the Global Fund, on a beachside conference area just north of Monrovia. The rest of the day was completely stimulating – due to both the content of the meeting and the setting itself.

Participants broke into groups of varying healthcare capacities, such as Home-based Care (HBC), Antiretroviral Treatment (ART), Information, Education, Communication (IEC), Behavior Change Communication (BCC), etc. I attended the HIV Counseling and Testing (HCT) section, and facilitated an exercise where the representatives discussed Liberia’s performance against HCT metrics and brainstormed action steps to addressed areas of underperformance. Moderating between the varying perspectives was fun, actually. Everyone was lively and opinionated, and only occasionally in agreement. By two o’clock we had listed five key steps, identified key actors and responsibilities for the steps, and estimated sources of financial and technical assistance.

At two we took lunch on the beach. Lunch in Liberia tends to be mid afternoon, and often takes more than an hour. So far, I’ve liked all of the dishes I’ve tried, save the lamb stew - though in all fairness, I think I got the unlucky bowl because mine came with a hoof. My favorite side, hands down, is fried plantain. The staples are rice and fufu, ground cassava root folded into a paste that seems a bit like a finer form of polenta. Sauces and stews vary, but always come drenched in oil (typically, palm or vegetable) and with plenty of spicy pepper to be mashed into the starch – if your nose doesn’t run, then it just isn’t hot enough.

We were lucky on Thursday, that the sky was perfectly clear and we could eat outside overlooking the beach. May through October is rainy season in Liberia, and the coastal regions can get 170 inches of rain during those months while inner counties receive less than half that. It’s cooler during the rainy season (about 27/28 C, or 80ish F) but unbelievably humid.

The rest of the afternoon was spent listening to each group present their next steps so we could formulate an aggregated action plan. Common themes through each presentation referenced the need for improved and standardized training of trainers (TOT), a national registry to track users of medical services, and a protocol for quality control. The action plan seems pretty daunting, but balanced by the recognition within the MoH of the need for these changes. We listened to most of the presentation but ducked out around four to head back to Monrovia to prepare the cars for the next day’s trip. On Friday, we planned to drive to the northeast counties of Nimba and Bong to distribute requested supplies, pull back at risk stock (materials about to expire) to redistribute to other counties, and assess whether the local facilities were following the testing algorithm and using resources efficiently. To do this, we had to collect the necessary supplies from Monrovia before the warehouse closed.

After gathering supplies we headed downtown for Chinese. There we met with a number of Yale fellows who were in town for the week to lead a conference on management strategies. To the surprise of many, Monrovia has a couple of reliably tasty restaurants. I’ve had good Chinese and sushi so far, though the fact that a CHAI member ordered in Chinese may have won us special treatment. The highlight for me for the night was a saying one of the fellows relayed from his time spent in Ethiopia. Apparently, when people come across hard times, it is common to say, "like a thorn from a monkey's butt." The logic is this: if a monkey falls from a tree into briers, then the first thing he must do is remove the thorns from his back side so he can sit down and get to work on the rest of his body. Essentially, the saying means "first thing's first." I think I may have to adopt it.

Friday started pretty early. We had to hit the road at seven to ensure that we had enough time to reach Ganta (our farthest destination in Nimba county) and get back to Monrovia before dark (because of the road conditions, it isn’t wise to drive after dark). It was great to get outside of Monrovia, get a sense of the counties, and see a couple drug depots and hospitals in person.

Liberia's country side is lush, green, tropical rain forest. The country is rich in natural resources - and not just diamonds. There are many farms of rice, fruits, and vegetables. The cash crop, though, is rubber. I'd heard of rubber cultivating techniques, but definitely never seen it before. To tap the rubber, manufacturers slash the trees making a large V mark, then drain the sap into bowls that are transported to second stage development. Manufacturers used to pay rubber collectors according the weight of their bowls until they realized people were placing small stones at the bottom - not they just cut into the thick sap to ensure the weight isn't thrown somehow. Firestone Tire and Rubber Company sources an enormous amount of rubber from Liberia. It's a very cool feeling to see the beginning of a good that we take for granted but has such an effect on our lives.

I saw two drug depots and hospitals during this first trip out into the counties, and I'm having trouble verbalizing my impressions. The first depot was managed with great care, but the basic needs were still just overwhelming. The same can be said of the hospital and second drug depot we visited. Because the counties operate on limited electricity, it is difficult to ensure the conditions necessary to store tests, treatments, and medical supplies and address the need of patients. For this reason, it is even more important that a process for assessing county needs and communicating to Monrovia is in place. Officials at the National AIDS Control Program have made a number of key reforms to their communication processes and supply chain management which have improved the flow of resources and information between Monrovia and the counties. The hope is that as we continue to work with the NACP and MoH, the process improvements made in these institutions will have a lateral effect on other government bodies.

I am still, admittedly, a bit overwhelmed by the breadth of material I need to absorb. My plan is to, while I'm in the States, do as much background reading as possible, about HIV/AIDS, antiretroviral treatments (ARVs), supply chain management, Liberia, and the Clinton Foundation... and any other relevant sources that I can get my hands on.