Wandor Introductions – Chiefdom Health Catchment Areas

Wandor Chiefdom, Kenema District
July 7, 2017

By Rupert Allan

Typical homemade wall chart in PHU (Primary Health Unit) [Photo Credit: Rupert Allan]
Health Centre in Tunghie – Catchment Area Record. Wandor/Gorama Mende Chiefdom

As I look into the village chief’s eyes, I realise that he is near to that age described as ‘in your prime’. And so are many of the chiefs I have met in Sierra Leone. We are bonding in a common understanding. I am trying to show him how the smartphone app I have installed on his phone works for SatNav. My trainee mappers are asking him questions to clarify on the Open StreetMap exactly where the community is. There are many Baarmas, and resources went haywire during Ebola here. We have ridden on the back of motorbikes driven with incredible skill up these rutted and rocky tracks to get here. We are deep in the heart of Diamond Country. We are trying to establish a community-sensitive format by which to represent these communities who are so seldom in contact with the outside world.

It is always weird to be treated with gratitude here. I appreciate it. I suppose I am privileged enough to be doing something which my extremely critical outlook can justify, yet which is fascinating and ultimately mitigating some of the problematics of cultural imperialism here. But we are standing on the shoulders of the giants who came before, and it feels somehow dishonest to enjoy the welcome that we invariably receive because others delivered all that life-saving healthcare. It wasn’t me inside that unbearably sweaty HazMat suit during the dark days of Ebola. I wasn’t here. I was in some other sweaty place on the other side of the continent, I guess, and working hard on another precarious community, but this particular battle was never mine.

We are developing a mapping team which can reach far into the forest and mountains of this area, to establish the basic facts of how to reach people, and how they can express the challenges of Water, Sanitation, Disease and Healthcare which encounter them at every move. To update and improve the medical map.

Memory drawn sketch map of PHUs in MSF project area, the best current map of health catchment area held in the regional Health Centre, northern Kenema District. [Photo Credit: Rupert Allan]
Randy is facing one of these very challenges today, here in this corner of the continent has been described to me as the ‘White Man’s Graveyard’. Malaria. We have left him sweating it out in the dark room at the back of the ‘guesthouse’. It came on amazingly quickly, in this district of Diamond Mines and rebel strongholds.

At some point on our ‘classroom’ on the concrete porch, we were explaining to our survey team one of the finer points about how to encourage the community to take ownership of the map. He suddenly turned to me and said ‘are you feeling cold?’ within ten minutes he was lying in bed, swooning, a shivering wreck. But he will be OK. Luckily, he has the tolerance and immune system of a well-nourished specimen from the Global North. And he has had it before.

Randy in Class, Seconds Before Feeling The Malaria Chill [Photo Credit: Rupert Allan]
But in any case, I had to go it alone supporting our star mapping coordinator Alberta, vetting and coaching our new team of mappers. I am the ‘Big Boss’ of this, but felt the weight somewhat, as Alberta started to complain of a headache, and I looked around me at the blank faces, and stepped-in to continue the session. She recovered quickly, but I carefully monitored Randy with half a logistician’s eye on the nearest hospital four hours (yet only 54km) away, down these ‘impassible’ bush roads. Things are rudimentary even here in the best guest house in town. Taking a shower is done by standing in a bucket (aka in Krio: ‘rubber’) of water next to a toilet bowl – the only feature in the small washroom, except for the huge drum of water.

But now, under my mosquito net, writing this, we are happy. It was a good day. We have a bright, interested, and intrepid bunch of new mappers, thrilled about having a free offline “Sat-Nav”  (OSMAND – Open StreetMap for Android) on their own smartphones. They are thrilled too, to be part of the plan to access better medical and civil assistance, and I must admit that riding down that crazy hill from the village, I was beaming with pride myself, to be part of such a scheme, once again, thanking those who so brilliantly came before us in this campaign to make things a little better.

Where do we send the Ambulance? [3]

Segbwema, Kailahun District, Sierra Leone
Monday June 12, 2017—Dispatch 3

By Randy Thomas Jones

Today I’ll return to the story about how contact tracing, maps and public health all connect the dots that form an arrow pointing us to come here to the verdant and vibrant atmosphere of West Africa, to gather people with Android phones, to find motorcycles with their drivers, and make maps of places that can literally be “off the map.” In many cases, being unrecognized means that voices from the hinterland are not noticed, and this is the first step to helping people say to the administrative systems of the modern world, “We are here.” In a way, an analogy could be that if one called for an ambulance in the modern world, one would expect to be asked, “Where are you?” And given an answer, to expect them to arrive. In low-income settings, sometimes the difference between being known and unknown is a difference between life and death.

With Nigel Jagbwem OSM
Screen shot, indicating example of geotagging photos as part of a data set. [Photo Credit: Rupert Allan]
Yesterday I was discussing the need for mapping in Sierra Leone, and how the lack of accurate maps and gazetteers hampered the response to Ebola in 2014. In Nigeria, on the other hand, extremely aggressive contact tracing did effectively stop the outbreak before it became an epidemic. Nigeria had the infrastructure available to a wealthier state that made it possible to ask the key question of where patients were from and receive an unambiguous answer. Sierra Leone has been declared Ebola-free for 18 months now, but Sierra Leone is still considered “At Risk,” because the virus is in the environment and could again transfer to the human population.

One of the things that becomes apparent after some consideration is that the creation of maps and an unambiguous gazetteer (which lists not only village names, but the association with higher administrative districts) is much better done before a crisis hits. And of course, registrars at clinics and hospitals have to understand why it is necessary to use them, and be insistent on a full answer when asking, “Where are you from,” or, as sometimes is the case when someone brings in a friend or relative, “Where is this person from?”

Dr. Monk is developing his portfolio to focus on both UK-based medical practice and Global Health for Alternative Certification in Core Medical Competence, enabling him to tailor his studies to his interest area of epidemiology, infectious diseases and microbiology. He’s a congenial ball of fire when he invites us to the local bar in Segbwema Thursday night, and he and Ivan happily trade stories, both of them enjoying the meeting of minds with similar obsessions. Ivan considers him a great resource as a friend to the project—the more typical situation is that doctors don’t pay that much attention to public health (again, that old bias of the consequentialists). Doctors, and quite rightly, tend to be Kantians.

Friday morning we walk up the hill from our guesthouse to meet Monk. Or, more precisely, he arrives at 8:00 in the morning with a typical British enthusiasm and a warm invitation to the canteen at the Nixon Memorial. A breakfast that is unusual, for the Western palate, composed of fish and rice, but I do remember the “Egg and Bread” from my visit to Ghana last year, and determine to track that down whenever possible!

motorcycle track
Typical of some percentage of village access trails, impossible to transverse with even a 4 wheel drive vehicle—walk or bike! [Photo Credit: Rupert Allan]
After breakfast, we take an extensive tour with Ed through the hospital find out that the Nixon Memorial Hospital has surprisingly good practices for registration. “Daddy” is the registrar at the outpatient desk, and takes great pride in his system for keeping track of patients. To the inexperienced eye, it looks like a haberdashery of file cards in randomly placed boxes. In fact, Daddy passes every inquiry regarding how individual patients’ records can be traced through his system. He has aspirations, and borrows a computer to practice his Excel at every opportunity from the hospital lab. Similarly, Betty, who manages the intakes on the wards, confidently pulls out scrolls of old records and points to one. “That would be in that one,” she says. Ivan rates them in the top 10% of facilities he has seen in low-income countries (the term he prefers to the usual terms “undeveloped / underdeveloped / developing”).

What started out seeming to be a quirky interest in records turns out to be only the “responsibility of care.” I’m getting enthusiastic about records myself at this point, and there is a certain kind of devotion to the practice that is as important as remembering to feed all of your children, and not leave one hungry.

Leveraging the goodwill that Monk has built, we make some very casual inquiries as to the possibility and interest for adding any columns to the intake books. Currently, the disambiguation of towns with the same name is done informally, depending on Betty and Daddy’s admittedly formidable memories. There are complications to this; one of the master books is a federal record that has a specified format that doesn’t meet standards for current best practice. But the answer is a tentative and provisional, “Yes, possibly.”

London to Haiti to Sierra Leone [2]

Kenema, Kenema District, Sierra Leone
Sunday, June 11, 2017—Dispatch 2

By Randy Thomas Jones

We are at the Internet café in Kenema, a town with a population large enough to sustain a full market(1). We could have used the visit for some purchasing, but the priority today is repairing some of our tech. The single independent server we have (Ivan usually brings about 5 of them to ensure redundancy) is inoperative, so he is currently engaged in the traditional activity of travellers since time immemorial—field hacking. It might be time soon for another order of cold water . . . one time is usually all it takes to clarify the issue for the ex pat of whether one is asking for cold water, or just water! And for another thing, the market is closed, the shipping containers that are one of the typical housing for small shops . . . all the small shanties that provide shade for the smaller suppliers are bare—it is Sunday.

kenema hardware store
Typical “hardware store”—a stall with various useful and peculiar items.

On a successful note, Ivan has just procured a piece of wire. Literally one piece of wire, but with the kind of resources that are available in a smaller African town, it was probably a good bet to give up after one wild goose chase in Segbwema this morning. Let the field hacking commence! To return to the introduction to our adventure, or, to use the more generally accepted term, “mission.”

In Haiti in 2010, after the earthquake, Gayton faced a similar problem to the one John Snow faced in London in 1854—cases of Cholera were beginning to arrive at the MSF hospital in Port-Au-Prince, and everyone knew that a second, potentially even more devastating disaster was developing fast. Gayton knew of Snow’s solution, but the problem was trying to identify the neighborhoods people were from was an impossible task.

To describe why the task was difficult perhaps can go back to what many might know from some rudimentary exposure to anthropology—many cultures have names for themselves that simply mean “The People” in the local language. Left to their own devices, people will name things in a vernacular fashion. Haitians were no different than any other people—they didn’t mind at all having dozens of similarly named streets called “Avenue of the Church, “ or “Market Street.” Of course, they know where they are from, but when they are coming into a medical facility, they may be too ill at that point to communicate the extra important information that can disambiguate the Patient Origin, the technical term used in the medical world. And if a person is coming in sick with Cholera, you know that they have only arrived after infecting several other people, who will either be arriving soon, or not even able to make the journey to look for help.

Cholera is actually possible to treat; mostly the issue is rehydration, while a person’s own immunity has a chance to successfully fight the infection. It is not necessarily any kind of heroic rocket science, but it is a daunting task that quickly becomes unmanageable in an outbreak situation. The stress on resources will quickly break any attempt at a logistical solution that relies on the Kantian idea of giving the all and best to each new patient. The outbreak needs to be stopped at its source, or many will die.

Recognizing the gravity of the situation in Haiti, Gayton had an idea . . . identify danger areas of outbreak properly, using modern technology—could Google possibly help? After a series of phone calls, Google sent Ka-Ping Yee, who had actually been invited to join Google in the very early days as a founder. Within a week he was on the ground. The organization Missing Maps (also one of our project partners) had already made what is called a base map, using the knowledge of Haitian diaspora volunteers looking through satellite imagery to name streets. With the help of British Red Cross and MSF UK, Ping and his partner were able to quickly scrap together code that enabled a visual dashboard to be used by administrators. Now it was possible to open a map of the city that showed the cases of Cholera as red dots—a “Heat Map.” At a glance, just like John Snow’s map, you could see where the highest incidence rates were located, and resources could be concentrated on where they were most needed.

motorbikes village
Surveyors at work doing their interviews, “Riders” (the motorcycle drivers typically engage and assist.

Jump to 2014, and now Gayton has been called to Sierra Leone in the height of the Ebola outbreak. Full quarantine protocols have been instituted for MSF staff . . . no one is even allowed to touch another human being during the time of their posting. It is clear that Ebola is another transmittable disease. At the height of the outbreak, 1.7 people were becoming infected out of every case. It was looking like a global apocalypse in a time frame of months. But again, the mathematics were germane—if the infection rate can be brought down to less than 1.0, the epidemic is stopped. Ebola also exists in the background environmental reservoir. It came originally into the human population through consumption of what is called “bush meat” in Africa—often unauthorized or even illegal hunting of wild animals for food sustenance. On its own, left in the forest, it is not much of a danger to humans, but once in the human world, it can become a specter of incredible danger.

At the height of the outbreak, the MSF Ebola treatment facility in Magburaka, Tonkolili District, in Sierra Leone had 110 patients, and effective contact tracing (That old question from John Snow: “Where are you from?”) could only be done for 20% of the patients. Why? Because many villages had identical, or very similar, names. Many people from different walks of life had to risk exposure to the disease to intervene against the developing catastrophe. Any contact with exposed people had to be ended, and here mapping had a sinister side—some villages with known outbreaks had to be forcibly isolated to delay the spread of the disease. The experience was heartbreaking, and MSF had a rotation of three shifts of personnel—one on the ground, while the second group was in recovery from the trauma, and the third group, which had sufficiently recovered, was on a vacation rest before heading back to the field. And the damnable thing was, that the outbreak could have been stopped cold (on this point, Gayton emphasizes by thunderclapping his hands together with a vigorous and defiant grief).

Had the availability of accurate maps and a gazetteer been available there is no doubt that the situation would have been ameliorated. As it was, 12,000 people died in West Africa, actually a testament to the sophistication of modern intervention strategies. It was a light toll, considering the nature of the jeopardy.

(1) The city of Kenema had a population of 200,354 in the 2015 Sierra Leone census. Wikipedia

Ebola and the Magpie

Wales, United Kingdom
May 28, 2017

By Rupert Allan

[Editor’s note: Here Rupert Allan describes his experience on an earlier trip to Sierra Leone in 2015, where he led a two week intensive training for Field Team Leaders, and managed an earlier surveying project.]

During the Ebola outbreak in West Africa, there was general panic. Our mapping project was born, but so too were many other systems. One such was the Magpie App, another lo-tech-meets-new-tech solution, this one for recording burials. Here is an impression of how I first came to hear of it:

It’s lunch time, and we are about to go out from our teaching classroom into the corridor to eat what gets brought in by the catering lady. Jollof Rice and Chicken. But then somebody mentions the Magpie.

It is a warm but cloudy day in the capital. We have been training for two days on the Data collection App Open Data Kit (ODK). Sierra Leone was mapped by motorbike using this downloadable software during the Ebola outbreak, in a (successful) contribution to getting a handle on stopping the disease. Already I have guarded myself against shaking too many hands or having other tactile contact with the people here – those magical comradery handshakes so memorable from the West Africa of years ago that I remember when, in 1989, I was building a school in the Liberian bush.

Field Team Leader Victor on the Guinea border-crossing issues.
“Cross Border and Kiosks” [Red Cross Video]

I have already heard from Victor of the way in which people would avoid the ‘Safe and Dignified Burial’ technique desperately encouraged by disaster relief organizations. Distraught and grieving people just wanted to be left alone to tend to the traditional intimate washing of bodies by all the family, but it is this very intimacy which had to be prevented by desperate humanitarian actors. Tales of how families would use their back door to take a body for burial over the porous borderline and into the neighbouring unregulated country are fascinating and initially amusing.

Somebody describes to me the Magpie app., the only way, but a depersonalized way – to keep abreast of the unfolding disaster at the time. Some of the details of what the ‘Enumerator’ was asked to log – safe geo-tagging, photographic data, all flies in the face of talks of ancient intimacy, reducing this kind of anonymous horrific evidence to a DATA BASE entry. It has been so very impersonal, but so critical for the survival of these ravaged but peace-loving communities, and it puts a lump firmly in my throat even now as I try to relate it.

But when you bear in mind that drivers in the capital, as my driver points out, don’t know how to react to the new traffic lights because more than two generations of drivers have passed since the last traffic lights were vandalized in the civil war, (another terror which was only just abating properly when Ebola struck) it makes you wonder what West Africa has done to deserve not only these natural disasters, but these assaults on their national identity. Sierra Leone has seen brothers slaughter brothers, and one cannot even console oneself with family social traditions of peace and intimacy, honoured since before the time of borders, white men, and territory. But one thing remains, and of course will always remain, which is that people are loving, human, and dignified, throughout, and regardless of, what has been heaped upon them.