Workforce
Community Health Workers
The community health workers sit on pews in an angulated semi-circle, listening with bodies hunched forward towards the master trainer. They have travelled as far away as Bonga to get here and the dust on their flip-flops and protruding toes hint of the miles walked. They are the leaders of their respective villages-- farmers, traditionally trained midwives, mothers, fathers, traders—selected to learn how to counsel their neighbors on family planning and to dispense condoms and oral and injectable contraceptives. Normally, this type of medical intervention would be the job of licensed medical professionals, but 60% of Liberian girls get pregnant before 18 with 30% of them attempting abortion at home. For older women, 1 in 125 will die in childbirth. Even if they survive, 10% of their offspring won’t.
So more needs to be done within the system. The results are not good enough and the status quo does not present future solutions. In a curious sequence of health logic, a sure fire way to make sure mothers and children don’t die unnecessarily in a county with 1 doctor per 30,000 citizens is to reduce the number of babies born in the first place and to prepare other types of people to fill medical roles. When in doubt, ask those you serve. 36% of Liberian women have unmet needs when it comes to contraception. 25-50% would opt for injectable contraception though only a quarter, due to issues of access, come back for subsequent shots. The new preference among women here is actually hormonal implants. Placed right under the skin of the inside of the arm through a jab-pull-dab procedure that takes about five minutes, the implant protects against pregnancy for five years without need for refill and without prerequisite consent of the man, who generally wants nothing to do with children or as many children as possible. The average woman in Liberia has six children making Liberia one of the most fertile countries in the world. It is fair to say that most women here would not voluntarily choose, in the broadest sense of the word, to have six children
“So you know what happens to a balloon when you blow it up too many times, Oh,” says the master trainer, “you tell me what happens.”
“It gets weak,” chant the community health workers almost in unison, “the balloon gets weak!”
“Yes,” says the trainer, “in fact, it can get so weak it can break. Can you see how this might happen to a young woman? A nice young Liberian woman has too many children. Has not three children, not four, not five, but six children. Six children! That woman risks her life having so many children, Oh!”
“The uterus can be so weak,” say the community health workers, “Six children is hard to bear, oh.”
The bilingual spirit
The dialogue is spontaneous and punctuated. The interaction feels like a fiery church sermon with the trainer exhorting and the community health workers affirming. We are actually in a church, which in turn has the feel (and smell) of a Bethlehem-esque barn. Once in a while, in meanders a careless chicken or ambling goat. Against the back wall there is a painted picture of Jesus with arms outstretched stating in two languages: Come yee get unyoked.
I had been worried. This family planning grant is delayed. USAID was slow in getting IRC the money needed to start the program. The Ministry was inconsistent about expanding the role of community health workers who are already challenged with treating diarrhea, pneumonia and malaria. The community health workers are not allowed to be paid a regular salary, making their compensation complicated. The family planning trainer from our organization did a lot of reassuring but appeared to take shortcuts in the preparatory work. “I have been doing this for years,” she said.
But we all came early. Doctor Gilian and I helped write out on poster board the agenda for the three days, the training objectives, rules of conduct and a pre-test. We reviewed the activities with the trainer and shortened and honed the modules, emphasizing skills training and group work. And then there comes a point, unless you want to micromanage everything limiting reach and scope, you simply have to let go. You play like you practice. We have practiced for weeks and it is time to play.
Studying the issues
“So you work already hard for the people in your villages,” the trainer continues, “but we are going to ask you to do more. Because we need you. Your neighbors and your families need you. Sometimes it is far to walk to the clinic. Sometimes that clinic is closed. But you are not closed. You do not close. Is that right?”
“That is right,” the health workers answer, “we do not close.”
“What did you say,” says the trainer, “You will help? You do not close!”
“We will help,” chant the workers, “We will not close!”
“I want to introduce my Bossman,” says the trainer. Eyes turn towards me and I am a little embarrassed. I know what is coming and I did not prepare, “he is Dr. Wilson. He has driven many hours from Monrovia to see that we get this training done right. He is responsible for us being together and getting educated about preventing the death of mothers. Let us hear from our bossman a few words of encouragement.”
Having no choice, I stand up from the side of the room next to the faded blue framed and shuttered window where I sit. I begin, “Thank you all for taking time out of your busy lives to come together, but please do not call me Bossman. We are colleagues. Call me Wilson. That is my name.”
The audience chuckles, “Wilson,” they say.
“We are here to do what has not been done before in Liberia,” I continue, “We know you already play a vital role in your community. You are treating Liberia’s most important diseases: Malaria, diarrhea and pneumonia and we applaud you for that. You must continue with that.”
“But too many women, sometimes even girls, in this country are dying needlessly because of something too simple. They are having children too young or having too many children to be good for their health. We want women in Liberia to have the number of children they want when they want as safely as they would want. This is the definition of family planning at its most basic. Can I get a shout if you hear me? If you know what I say?”
There is punctuated applause, “We hear you,” the workers say.
“You can hear what he says,” yells the trainer.
“We hear what he says!” yell back the workers.
Teaching community health workers to give injectable contraceptives
“You are going to learn how to help families plan their pregnancies. No more accidents. No more surprises. No more risks,” I say, “Over the next three days you will learn the science behind family planning. You will learn more counseling techniques. You will learn how to record what you do. And finally you will learn how to give contraceptives in pill or shot form. Does that sound good to you? Is that your understanding of your time with us for the next three days?”
The audience seems genuinely excited. I appreciate their energy and wonder why Western audiences in contrast refuse to care so recklessly. There is much to do. Many of the workers cannot write or read which poses a significant problem to record keeping. Job aids in the form of pictures still need to be created. We have to make sure that the Ministry brings in the necessary supplies. And damn it if I am not going to figure out a way to get these community health workers paid.
Job aids
But we have taken the first giant step. We are in Konia, at a church, with community members from across the County responding to an important problem in the most fundamental way. We are bringing simple effective interventions to the doorsteps of women. We are training those whom are their neighbors to aid in their care.
A light breeze blows and at least an hour before the hot. Every fifteen minutes or so there is a screech, a beep and a squawk preceding the animal that is about to enter our place.
Skin in the game. Practicing injections on the teacher
