(LIBERIA) Liberia’s far-flung, rural regions are beset by serious challenges. After a 14-year civil war that killed 250,000 people, not only was the health care system devastated and most hospitals and clinics destroyed, but it is often overlooked that over 70% of Liberia is rural where basic facilities for, and access to technologies are severely lacking.

Communication, for example, faces many obstacles:

• Cell phone coverage range is unpredictable – “no service” is a frequent message on the screen.
• The person you had been trying to reach by phone later explains “I am finished” – he has no more minutes on his SIM card.
• There is no newspaper to be seen in rural areas – if one did arrive, the news would be more than a few days old.
• Many people are non-literate.
• Radios are unaffordable…and if a family were to obtain a radio, there are no radio stations in “range”.
• Computer? Email? Internet? – “No, we don’t have those.”

This past week we waited for four days to establish contact with Elijah, our World Renew Project Coordinator, who is ‘out there’, somewhere.

In the midst of this difficult situation, Liberia’s community health workers have become a vital source of primary care and information for villagers who otherwise might have to walk for days to seek treatment.

Eric Bumbo is a community health nurse in a “hard-to-reach” county called Grand Kru. He has two “homes.” One is in Monrovia where he comes once each month for a few days of in-depth training and to visit his wife and son. The other is in Grand Kru. Although only 600 km apart, due to road conditions it takes two very, very long days to travel between the two homes. Many of the communities in Grand Kru are inaccessible by road. It is Eric’s challenge to transmit important health messages to these isolated communities. He works within these rural communities and has been given the responsibility of teaching and promoting health care on a large variety of issues. How is it possible for one person to do this successfully? We had a good discussion with Eric and learned how he accomplishes this massive mission.

A system has been developed whereby each community chooses one or two people to take on a front-line health care role. They are called general Community Health Volunteers (gCHVs). It is considered an honour to be chosen and indicates a strong respect and trust for this person. Along with a strong sense of commitment, the qualifications for this position are that the gCHV must be able to read and write English and be able to converse in the language of the local community. Eric, as the community health nurse, works through these volunteers to get health messages out to all of these isolated communities. CHAL effectively ‘piggy backs’ on to this system as they implement various projects.

"The maternal/child mortality rate is very high in Liberia. The maternal death rate is 994 in 100,000 deliveries. 35%  (45% rural areas) of women/girls have their first babies between 14 – 18 years of age. In every 1,000 births, 71 newborns will not live. One in nine children will die before their fifth birthday!"

The job of the gCHVs is to do health training. To do this they travel mostly on foot, teaching from community to community, from family to family and from person to person. During the Ebola season their emphasis has been on infection and prevention control (IPC), teaching people that Ebola is real and dangerous. To people who previously refused to do hand washing, the gCHVs stressed the importance of doing so with soap or chlorine and if these were not available, with ashes. They discouraged touch in general and even indirect touch through clothing.

If anyone showed signs of a fever, vomiting, diarrhea or a headache (Ebola symptoms), their family was instructed to contact the local leader immediately, and if possible, to ‘dial 4455 quick-quick’. While waiting for the ambulance, car, or “hammock” (stretcher”), the gCHVs would administer oral rehydration salts, encourage plenty of fluids and give some medication (if available) to fight the fever without ever touching the person.

Part of their teaching was to explain to family members how they could safely care for the person in their home until help arrived. The gCHVs distributed flyers, when available, to help explain Ebola prevention methods and for the people to keep as a visible reminder.

Another subject that the gCHVs are knowledgeable about is malaria prevention and its treatment. One NGO has a project affecting a large part of Liberia in which mosquito nets (three per household) are distributed along with careful instructions: “Don’t put the net in the sun or the mosquito repellant it has been sprayed with will dissolve.” “Malaria is especially dangerous for small children and pregnant women.” “Use your nets every night on every bed, tuck them in carefully and mend any holes that appear.” “Don’t sell your net and don’t use it for fishing”!

To help treat general fevers the gCHVs give out oral rehydration salts or paracetamol and encourage sponge baths. If this is not effective, they refer the patient to the nearest clinic. There is a good chance that he/she has malaria, a very prevalent disease here in Liberia that needs to be treated with anti-malarial medication.

Trained (on the job) Traditional Midwives (TTM) continue to be prevalent in these communities. gCHVs encourage all pregnant women to get full prenatal care, deliver their babies in the nearest clinic and receive postnatal care, all from a Certified Midwife (CM). If there are complications they are sent from the clinic to a health center where there is a Physician’s Assistant (PA). Some clinics have a very basic maternity waiting home so women can stay there for the week leading up to their deliveries. This is to help prevent the spontaneous births that take place on the long walk to the clinic. However, many prefer to stay home and use the TTMs for their births.

The maternal/child mortality rate is very high in Liberia. The maternal death rate is 994 in 100,000 deliveries. Thirty five percent of women/girls have their first babies between 14 and 18 years of age (45% in rural areas). By the ages of 20 – 24, 85% of Liberian women will have had a child. In every 1,000 births, 71 newborns will not live. One in nine children will die before their fifth birthday!

To combat these statistics, gCHVs are trained to teach better peri-natal standards (called “Safe Motherhood” here), to stress the importance of taking babies and children for the recommended vaccines and to share the best practices for sanitation, hygiene and safe drinking water. What a huge job and what great responsibility they have!

Watching some of these dauntless gCHVs at work spreading health messages has been inspiring. 

Blessings,

Harry and Annie Bergshoeff

International Relief Managers
Liberia