Shocking Inequity

(These women are Traditional Birth Attendants in Kenema District, Sierra Leone. They are greeting me with a traditional welcome.)

Much of my work here in Sierra Leone is centered around reproductive health care and child health care. Public health programs in the “developing world” provide services to women of reproductive age such as family planning, antenatal care, assisted births and postnatal care, as well as for children under the age of five for malnutrition, malaria, pneumonia and diarrhea (the leading causes of death). There is a wealth of evidence that health interventions in these areas for these two demographics have the greatest impact on the population’s health.

Simply put, they are life saving.

The figures comparing mortality rates for Sierra Leone to the United States are shocking.

The under five mortality rate, which tells us how many children under five die within a timeframe, is expressed per 1,000 live births. It answers the question: for every 1,000 births that occur, how many children under the age of five perish?

In the United States it is 7. In Sierra Leone it is 156.

Another significant indicator is the maternal mortality ratio, which tells us how many women die from pregnancy, childbirth, or in the postpartum period (42 days). This indicator is expressed per 100,000 live births. It answers the question: for every 100,000 births that occur, how many women are dying from pregnancy or childbirth?

In the United States it is 28. In Sierra Leone it is 1,165.

Globally, having children is one of the most dangerous experiences a woman encounters. It is the second leading cause of death in women of reproductive age (ages 14 to 44) (HIV/AIDS is the number one cause of death).

99% of ALL maternal deaths worldwide occur in “developing” countries.

This is shocking inequity.

*Mortality data is from DHS and UNICEF.


Coconut-the local ORS

coconut seller2

(ORS is Oral Rehydration Salts, which are used commonly in community health programs as treatment for children with diarrhea, cholera patients, and now Ebola patients. When I told one of our Sierra Leonean drivers that I am loving the coconuts here, he said “It is good for ‘d’ body, it is our ORS!”)

The expat world in Sierra Leone is very surreal. You have a driver, you live in a place far above local purchasing power, you eat at restaurants that cater to expats. It’s very insular and it exists entirely parallel to life as a national. I’ve found it very hard to have any authentic experiences here.

Coconuts are my one exception.

I sneak out of the office compound and take a walk down one of the busiest roads in Freetown, cross the street and hope not to die (I try and wait for a local to dart into the traffic so I can cross at the same time-safety in numbers, right?), and stop at the petrol station where several people are selling items to passers by.

I go and ask the gentleman for a coconut, who has a wheelbarrow full of them. He asks me which one I want (sometimes, sometimes he just chooses for me) and proceeds to use his machete to whack off the outer layer, tap on it (to hear how much liquid is inside?), and cut a round hole at the top. I say thank you, take it from him and stand there to drink the contents and then hand it back. He whacks it open and scrapes out the meat and hands it to me. I pay him 2,000 leones (about 40 cents) and remain standing there eating the meat and then toss the husk into the back of the wheelbarrow with all the others.

And then I dart back across the street, feeling really proud of myself.

It is my one activity that makes me feel like I’m actually experiencing something of Sierra Leone.

I’ve never had fresh coconut before coming here and now I swear by it. I’m sure going to miss it. It just wouldn’t be the same buying it from a grocery store (nor do I have the machete skills for such a task).


I’ve been sucked into the foodie blogosphere, which is at once a yummy exploration and at the same time excruciatingly masochistic as my food options here in Sierra Leone are limited.

It isn’t a surprise to find that almost every food blog has an index of diet friendly recipes. But, what has surprised me is that every food blog has so many categories of diets.

It seems to be a very Western notion to describe one’s diet; like we are using our food choices as a way to add to our list of labels. It’s kind of a funny way in which we identify ourselves. “Hi, I’m Saundra and I’m wheat free, sugar free, and vegetarian though I eat fish…” (I’m none of those, btw).

Even for those of us who, thankfully, have no food allergies, we still tend to adhere to a diet or label our noshing habits. And inevitably, it changes with time, with age, with new research, and probably most often with new food fads.

I went from SAD, to vegetarian, to organic, to local, to whole foods, to omnivore (yes, I’ve always eaten dairy). These days, in my grass fed meat eating/raw milk/pastured eggs/organic/local veg eating life, I find the Weston A. Price dietary guidelines make the most sense.  They are research based and advocate grass fed meat, lots of good fats, and raw milk from pastured cows.

Any diet recommending butter is a diet for me! Check them out:

Half Way

I’m exactly half way through my time in Sierra Leone.

There were a number of reasons I chose to re-immerse myself in humanitarian aid work. If I am to be brutally honest with myself (and you), I came to Sierra Leone because I needed to feel purposeful again. I was in a place without meaningful work, feeling rejection and a loss of confidence from an abrupt fall out of a business start up, and generally feeling direction-less and unsure of where to find purpose.

I turned to what I have known in the past, what I spent years preparing for, for the issues I still feel compelled by (in this case the health consequences of the ebola outbreak). I was nervous and excited about returning to the field. I came with an open mind – and the question of whether this could be the beginning of a new chapter of global health work. I really thought it could be.

The answers have been loud and clear. I am grateful for such clarity and for the affirmation that the life of land and family that I dream of is just as valuable as any other pursuit.

When I’m not straining my eyesight with spreadsheets and feeling the ills of sitting 9+ hours a day, I am dreaming of settling into a place, the daily work of chores of home and farm, and starting a family.

I am very grateful I have had the opportunity to take this job. I hope the extremely small accomplishments I leave behind will be beneficial to the efforts. But I just don’t have the all consuming passion for it-to live this life of constant travel, of hours and hours of computer work sitting at a desk, the conversations with colleagues knowing that even the friendships made will never have the time to flourish.

It reminds me of the quote by Lawrence LeShan:

Don’t worry about what the world wants from you, worry about what makes you come alive. Because what the world really needs is people who are alive.

I know what makes me come alive.

I look forward to returning home with a new appreciation for the small things, for relationships, for a place in community, for work that I love (even if it doesn’t require a degree), for family.

The countdown begins.

Culture of Aid

There’s definitely a certain type of person that chooses to do aid work. It requires a lot of travel to difficult environments, leaving your loved ones for extended periods of time and often with very little notice. The work seems to attract wanderlusts and misfits. The cadre of responders to the Ebola outbreak are a slightly different group of recruits than in my past aid work, which recruited the typical humanitarian aid worker assigned to protracted crises. The expats here in Sierra Leone comprise a mix of humanitarian aid workers (like myself), many clinicians with varying experience in these contexts, those with military backgrounds for the logistic response, and emergency responders who thrive on the chaos of the immediate aftermath. It’s a strange mix and I have to say I don’t connect with most. This is the first post I’ve had where I am spending most of my time in the capital and while I appreciate the amenities, it’s such a surreal experience going to the Radisson after work sitting amongst a patio full of white people looking like they came from their DC office and begin their evening of alcohol and smokes.

There’s always an expat economy when we flood an area for a humanitarian response, but here it is stark. Usually, there’s some shopping at local markets, only a couple of restaurants available, and one or two hotels that journalists stay in. Because of the enormity of the response, many of us are staying at hotels, there a quite a few restaurants to eat at (and without a kitchen, we only eat out), and then there are the swimming pools.

I have to say that I do appreciate having a place to go outside of the hotel and office. Freetown is reasonably safe, but I’ve found the harassment to be far greater here than I’ve experienced elsewhere. It certainly isn’t relaxing to take a walk in town.

I think the adjective that best describes my feelings about the mission (external to the job itself) is disappointing.

I’ve seen a couple of episodes of prostitution-white male expats escorting Sierra Leonean women. Exploitation of this sort is absolutely not tolerated by the major agencies, which have strict policies about such behavior. It violates humanitarian principles and reflects on all of us. Unfortunately, I haven’t known who these men are or whom they work for or I would absolutely call their heads of office.

That sort of behavior also poses risk of transmission to others. We are under a strict no touch policy, those who are directly exposed to infected or suspected patients and those that work solely in the office. Those men obviously don’t care too much.

I feel disappointment that the environment here isn’t one of a team working together for a common cause-even though that’s surely what everyone is doing. Instead, it’s a bunch of misfits with habits that I don’t share or with dubious characters.

I keep mostly to myself and just try and concentrate on my job. May can’t come soon enough.

Kenema Isolation Kenema Clinic

Above (top) is an isolation unit for people who come to the community health clinic (below) and who are suspected Ebola cases. They wait until an “ambulance” comes to take them to a treatment unit. These were taken in Kenema District.

Milk Magic

My cows won’t be giving us milk until late summer (IF they were bred successfully in December). I can’t wait to have raw milk coming into the kitchen every day. It’s so comforting to have a jar full of fresh milk.

People who have never tasted raw milk are always a little squeamish. They want to know how it tastes different from the milk on the store shelf. The best comparison I can come up with is the difference in taste between a store bought egg and a fresh egg from a pastured chicken. They are both eggs, but certainly not equivalent. No one can possibly go back to store bought eggs once they taste a fresh egg. That’s my experience with milk.

Raw milk feels creamy, rich and full in your mouth. It’s lusciously thick and sweet.

Please do yourself a favor and find a (clean!) source of raw milk. It will enrich your life exponentially. This is no exaggeration.

With a cow in milk, having it in such abundance on a daily basis means there’s a lot of opportunity to turn that milk into something else delicious-it’s like magic!

Here’s a list of everything that you can turn milk into (well the cheese category is limited to a few, easy to make, fresh cheeses):

Cream (skimmed off the top)

Whipped Cream

Kefir (uses starter grains)

Clabbered Milk (ONLY with raw milk)

Butter (cultured or not, salted or not, pasteurized or not, flavored or not)

Buttermilk (cultured!)

Yogurt (cream on top, skimmed, strained or drinkable)

Creme Fraiche (cultured cream)

Cottage Cheese

Cream Cheese

Sour Cream

Quark (my FAVORITE farmer’s cheese)

Ice Cream (buttermilk ice cream is on the top of my list)

The Battle to Zero

Matter magazine published an article on the loss of one of Sierra Leone’s most talented physicians, Dr. Sheik Hummar Khan. The Ebola outbreak has taken an enormous toll on the health system, with the death of hundreds of skilled clinicians who became infected whilst caring for Ebola patients.

Ebola has terrified communities, with its devastating case fatality rate and rapid onset. While we’ve seen the incidence rate decline dramatically over the past two months, new cases ARE still being confirmed. Where one case equates to an outbreak, the on going confirmation of new cases is frustrating efforts to eradicate the virus.

I’m currently working in Sierra Leone on health programming with an international organization. It’s very evident that the outbreak has and will continue to have long term effects on social and economic recovery. Schools have closed, businesses have shut down, movement is restricted, hundreds of children have been orphaned and the stigma survivors face leaves them with an uncertain future.

The road to recovery won’t end with zero cases, but first we just have to get to ZERO.