Access to Health Care in Sierra Leone: The Experience of Poor, Rural Women

My thesis on barriers to health care for women in Sierra Leone was officially submitted last week. For anyone who is interested in reading it, I have publicly posted it online: Clare's thesis via GoogleDocs. You are welcome to read and share with others. Please feel free to share any comments on the work with me via the blog or privately by email.

I would like to express my deep thanks to all the women in Sierra Leone who participated in this research, to all my friends and colleagues in Sierra Leone who helped me with this work, to my supervisors at Carleton for their guidance and support, and to my family and friends for their love and encouragement.

Back in Canada

Well, here I am, back at home in Halifax. The trip from Sierra Leone was relatively uneventful. I managed to meet a couple of people at the airport in Lungi, and chatting with them helped pass the almost 8 hours we had to wait before the flight left. They both work for an organization called Orphfund that helps abandoned and orphaned children. They have a couple of projects in Sierra Leone, as well as in a few other countries.

The only downside of my travels home is that one of my suitcases didn't make it. I am still hoping that it will come back to me eventually - it hasn't officially been declared lost yet. While there was nothing of significant monetary value in it, it did contain almost all the souvenirs and gifts I bought to bring back with me, so I will be sad if it doesn't turn up.

It's really nice to be home, especially with the holidays about to start. It's amazing how quickly everything here feels comfortable and familiar to me again. Things here are basically the same - almost like I was never away at all. Although being home is great, it's strange too. I went grocery shopping yesterday and found the whole experience slightly weird. I kept staring at all the food and thinking about people I left behind in Sierra Leone that don't have enough to eat. It really drove home the inequality that exists in our world, and the fact that there are enough resources available to meet our needs globally. It's just a coordination problem that they can't get to the people that need them. I mean do we really need 500 kinds of salad dressing to choose from? Couldn't some of that money and food be diverted to others? Obviously, it's not that simple, but it does make you wish that there was a way it could be simple.

Wishing all my friends and family in Sierra Leone, Canada, and all over the world a very Merry Christmas!

Goodbye Sierra Leone

I'm leaving Mapaki in about an hour for the airport, so this will be my final post from Sierra Leone. It's been an amazing experience, and it's sad to say goodbye, but I am really looking forward to being home again.

I will continue to post on this blog once I return to Canada. There are a few more topics I want to write about, and I want to be able to post more about my thoughts on the experience after having a bit more distance from it. So you have not heard the last from me yet! :-)

Remember, you can always keep up to date with what's happening here via Carolyn van Gurp's blog: http://cvangurp2.blogspot.com/. Carolyn will be returning to Sierra Leone in late January.

Also, if any of you are looking for last minute Christmas/holiday gifts for that person that's hard to buy for, consider making a donation to PSI or cdpeace in their name. Check out the websites for more information:
cdpeace
Peaceful Schools International
You can also donate to support the work in Sierra Leone directly with PSI's gifts of peace for Sierra Leone.

Departures and Arrivals

Tomorrow I am leaving Sierra Leone. Hard to believe that my time here is almost over. As I get ready to leave, here are some thoughts on the things that I will miss in Sierra Leone, and the things about going home that I am looking forward to.

Things I will miss about Sierra Leone
The people: I have made some wonderful friends here, both locals and other ex-pats, who I will miss a lot when I leave. I’ll miss the kids I say hello to in Mapaki every morning. I’ll miss all of the cdpeace staff, and the teachers I’ve been working with. I will miss all the people of Mapaki, even the ones that I don’t know well. People here have been so warm and generous. I’m always amazed by those who have so little stopping by to bring me a small gift of fruit or corn or a coconut. Everyone here has made me feel so welcome, and it will be very sad to say good bye.

The weather: I think I probably picked the nicest months to be in Sierra Leone. It really has not been as hot as I thought it would be, and in the part of the rainy season I was here for it rained mostly at night so it didn’t affect me too much. I love being able to go out without even thinking about needing a sweater, jacket, or even a long-sleeve shirt. I love being out in the sun, or sitting in the cool shade on a warm day. I could live permanently in a climate like this, that’s for sure. It’s going to be a big shock going back straight into winter.

The food: I have come to love the food here. The rice I eat is mostly the local rice, and it’s really good. Actually, all the food I eat in Mapaki is generally local – it’s nice to know I’m lowering my impact on the planet by reducing my “food miles” while I’m here. I love the different sauces (groundnut soup, potato leaves, cassava leaves, squash) and will have to experiment to see if I can reproduce them at home (I know you can get cassava leaves in Halifax, so am looking forward to that!). I also love the fresh fruit here – oranges, grapefruits, papaya and pineapple have all been in season while I’ve been here. There’s nothing like the taste of a fruit that is fresh off the tree. I’ve never had such delicious pineapple and papaya or such flavourful oranges and grapefruit! The coconuts are great too.

The sense of community: there is such a strong sense of community here, in Mapaki and in the other communities I’ve visited. People look out for and care for one another. Decisions are made together by the community after discussion and debate. Problems are resolved locally by elders. People know their neighbours and greet them every day. I will definitely miss this when I go back to Canada, and I think I will work harder to get to know my own neighbours at home.

The sky: the sky here is often so amazing to look at. During the rainy season there were piles of clouds that looked so different from what we see in Canada, and lightning that would light up the whole sky like daylight. I’ve seen beautiful sunrises and sunsets, and the stars in the night sky are incredible. That’s one of the benefits of not having electricity – without electric light, the sky is so much clearer and more beautiful, especially at night. I never knew there was such a difference in light at night when there’s a full moon in the sky compared to when there’s no moon.

The music: I love the fact that people here are always singing, dancing and drumming. Even though they don’t have much, they always find a way to have fun, and they love to dance and sing! I think if people in Canada sang and danced more, we all might be a little more relaxed about things.

Things I am looking forward to about going home
Family and friends: Of course the thing I am looking forward to the most about going home is seeing my family and friends, and especially my husband. Even though I have made new friends here, I miss my people at home a lot and can’t wait to see everyone again!

Electricity and running water: A close second on the list of things I am looking forward to at home are the modern conveniences of electricity and running water (hot showers, here I come!). Actually, I could probably live for a long time without running water, especially in a warm climate. Here in Mapaki I have my shower in a bag and my indoor toilet, and someone else carries my water in, so I really have it pretty good. I don’t miss the hot water because it’s usually too warm for a hot shower anyways :-) If I had to use a pit latrine or haul my own water every day, I guess I might feel differently, but as it stands, the running water I could live without. Electricity, however, is another matter. I never realised how much I love and appreciate having regular electricity. It especially makes a difference at night. When it gets dark at 7 pm and you don’t have electric light, there aren’t too many options except to go to bed. Also, the lack of regular electricity can be a big barrier to getting work done and being efficient. Electricity is definitely one of the things that I have a new appreciation for after being here. I’m also looking forward to the other modern conveniences that come along with electricity: washing machine, coffee maker, refrigeration, microwave, etc.

Food!!!: Although the food here is tasty, there really isn’t much variety in the diet, and it’s not all that healthy. Vegetables are not readily available in Mapaki, and the cooking is done with a lot of oil and salt. Along with specific foods like broccoli, asparagus, cheese, and yogurt, I have really missed the food variety I am used to. I am looking forward to cooking for myself, grocery shopping, and accessing the wide variety of foods we are lucky enough to have available to us in Canada. I also desperately miss real coffee (I’ve been drinking instant since I got here) and am SO looking forward to my first cup in many months in the airport at Heathrow when I arrive there :-)

Being ignored: One of the things that is difficult about being here is constantly being noticed as a white person (see my previous blog about this – http://clareinternational.blogspot.com/2009/12/black-and-white.html). I must admit that I am really looking forward to being able to blend into a crowd again. To be able to walk down the street without being called after, and to not being particularly noticed everywhere I go. I am sure that I will appreciate anonymity even more now than I used to.

Comfort: Sierra Leone is not the most comfortable country. The beds tend to be either too hard or too soft. My working environment is not very ergonomically correct and this causes me some problems sometimes. There is never a couch to lie down on, only chairs to sit in. I am looking forward to sleeping in my own comfy bed, lying on my own comfy couch, and sitting at my own desk in my own office chair, all adjusted for me. I’m even looking forward to snuggling up in my housecoat under a blanket because it will be cold winter when I arrive home (brrr!), although I’m not sure how long that will last!

A woman’s work is never done

Today I went to a gender sensitization workshop organized and presented by cdpeace. Although it was in Temne, I managed to catch some of what was being said through an interpreter. It really made me think about the role of women here in Sierra Leone. There are beginning to be more women in positions of power here, but there is still a long way to go, but there is still a long way to go for the average woman in Sierra Leone, especially in rural areas.

One major area is work. This was really emphasized in a small group activity we did at the workshop. Each group was assigned a person (man, woman, boy and girl) and had to write down all the activities that person typically did in a day. On the list for men were the following:
- Pray
- Rest and eat breakfast
- Work
- Rest and eat supper
- Go to sleep

Although many men here do hard physical labour, the rest of the time they don’t have too much work to do. The list for a woman, on the other hand, looked like this:
- Get up and get water for your husband and children to wash
- Prepare breakfast
- Sweep the house and make the bed
- Get the children ready for school
- Go to work (working on the farm doing weeding or harvesting, petty trading activities, or perhaps an office job in a few cases)
- Go to the market to get food for meals
- Start cooking around 2 or 3 pm to prepare the evening meal
- Clean up after cooking and prepare the children for bed
- “Answer the call of your husband” – euphemism for sex
- Sleep

So, as you can see from these lists, women have many more tasks for which they are responsible than men. Women here are responsible for all domestic work and all child-rearing duties. So they clean the house, do laundry, purchase and prepare food, take care of the children, and collect water and wood for everyone’s use. They work on the farm, doing all the weeding and a lot of the harvesting work, and they process the food harvested as well (e.g. pounding rice, making palm oil, etc.).

In the workshop, the speakers talked a lot about gender roles and how we should begin to accept that men can do work considered “women’s work” and vice versa. I agree that work and the burden of work is an important area, and maybe that is where gender equality begins. But the gender inequality here of course goes deeper than just surface work tasks. In relationships, women are generally not treated as equals. The man is considered head of the household. He makes all the decisions, controls the money, and in turn is responsible for taking care of his wife (or wives – polygamy is still fairly common here) and children. Women often do not have access to money and have no say in decision-making for the household. And if the husband leaves, this can leave the woman and her children in very dire financial straits. It is still common to arrange marriages here, and to pay a bride price.

There is a lot of work still to be done to improve gender equality in the country, and I think it’s great that cdpeace is working in this area, especially in rural communities. Will one or two workshops change societal attitudes? No, certainly not. But societal change happens slowly over time, and the more people are exposed to the idea of men and women being equal, the better. So even the small things, like this workshop, can help a little bit.

The library

I can’t believe that somehow I have not yet written a post specifically about the Mapaki community library. Many of my evenings in Mapaki so far have been spent in the library. The library is open Monday to Friday evenings, from 7:30 – 9:30, or until the battery, charged during the day by the solar panel, runs out of juice, whichever comes first. If it’s raining the library doesn’t open, and if it is open, the kids usually scatter for home at the first hint of raindrops.

The library here is really quite incredible (a few photos here: http://picasaweb.google.ca/clarepoulev/MapakiLibrary02#, although they don't really do it justice!), and is already known about quite widely in the country. The library is so popular that the younger children have to be limited to one visit per week (Grades 1 – 5 on Monday to Friday evenings). The older children (Grades 6 and JSS students) and adults can come any evening. On any given night there could be 15 – 30 people in the library. Young kids looking at books, older kids studying or doing homework, volunteer teachers looking at teaching resources, and adults from the community reading or having a computer lesson. I often go with a book and just read in the electric light. Sometimes I bring my computer and do a bit of work, although this tends to attract a lot of attention :-)

One of the great things about the library is that it is open in the evenings. In a community where electric light is rare or non-existent, it really helps the students to have extra light at night by which to study.

The story of how the library came to be built is worth repeating for those who don’t know it. The following was written by Carolyn van Gurp, PSI volunteer Regional Coordinator for Sierra Leone, and was published in the January 2009 issue of Peace Talks International, PSI’s quarterly newsletter for our member schools.

New Library for Mapaki
by Carolyn van Gurp

Thank goodness the people of Paki Masabong ignored my advice. “No, it can’t be done, money’s not there,” was my response when I was told the community really wanted to build a library to serve the needs of the hundreds of children and adults who were trying each evening to pack into the small temporary room that was serving as community library in this small chiefdom, where only about one in thirty adults have been to school.

Here we are, one year later, preparing for the big feast planned to thank the many youths who donated their time, labour and local materials to make this dream a reality. A beautiful, spacious, well-stocked, solar-powered, internet-equipped library which is the talk of the country (the only village-based library of its kind in Sierra Leone) is about to officially open its doors (we expect the President to be here for the opening). And this dream is the result, not of the initiative of a wellheeled, well-funded NGO, but rather the determination and hard work of the people of this small community and their visionary Paramount Chief.

All this started two years ago when a visitor to this community, seeing no books in the schools but observing four teenage boys each evening poring over a decades-old dog-eared Shakespeare book, sent over several boxes of books which were then set up in a room designated as community library in a just-built “guest house” in the village. Lit in the evenings with a single bulb powered by a donated solar panel and battery and staffed by a volunteer teacher, this became such a popular and crowded place that each child in the village had to be limited to one visit to the library per week and there was no room for adults to squeeze in.

That’s when the Paramount Chief and elders intervened. “We need a library…we need a place where both adults and children can come and read and study and learn about the world.” Unable to envision a source of funding such an undertaking, I was sceptical. The community, though, knew it had to and could be done and at a community meeting called to discuss the library, two families came together to donate prime land in the centre of the village for its construction. The youth, meanwhile, organized in three work brigades representing all sections of the village, started making the mud bricks needed for walls and footings. Each day school children would stop on their way home from school to carry endless buckets of water for the youth who sweltered in the hot dry season sun
to make enough mud bricks for a large fourroom library. Just in time to cover the walls and protect the mud bricks before the rains came, the community received a small grant to purchase zinc roofing and cement and the outside shell of the library was completed.

Over the ensuing months, the youth of the village developed hands-on experience and training in carpentry, masonry, wiring, painting, boardmaking, and woodworking as they volunteered their time to complete the library.

And what a library it is! Housing an amazing collection of hand-picked culturally-relevant visually-rich books about people, animals, plants and the planet and stocked with several laptops and digital video and still cameras donated from Canada, the library has a donated satellite internet connection which has been put to some very unique uses (a Skype wedding, agricultural research, discussions between youth here and in Yukon, video postings, etc.).

Staffed by two volunteer teachers living in the community, the library will be hosting classes for adults and children in health education, computer basics and functional literacy, workshops for teachers on a wide range of topics and will serve as a chiefdom “lending” centre for learning materials for community schools.

The community has asked me to pass on thanks to the many people and institutions that have come along on this journey and contributed to making this a place of pride for all. A huge thanks to CIDA, Friends of Sierra Leone in the USA, Centre for Development and Peace Education (cdpeace) and Peaceful Schools International, staff of Halifax Film, Green Solutions and the kind and caring individual donors who have contributed in various ways.

Black and white

Since I arrived in Sierra Leone, I have been thinking about the experience of being a white person here, and this post has been in various stages of draft, both in my head and on the computer, for some time. It’s hard to describe the experience without it coming out sounding wrong somehow . . . but I also think it’s an important thing to try and explain, so here it goes.

As a white person in Canada, I have never been personally touched by issues of race. Here in Sierra Leone, my whiteness is pretty much always obvious to me (as well as to everyone around me). In general, being white here means that you can never blend in, get lost in a crowd, or go unnoticed. This is especially true in the villages, but even in Freetown (the capital) you get stares and attention (although much less so than in Makeni, the country’s third largest city, where stares, greetings and the constant cry of “opotho, opotho!” from children and sometimes adults is common – “opotho” means “white person” in Temne, the local language most common in the north). Aside from “opotho”, other terms that have been used to address me range from “hey white” to “white girl" (or worse, "white man") to “hey you” to “Ma” or “Auntie” (these last 2 at least show some respect). I know that these greetings are generally not intended in an offensive way, but they can definitely come off sounding rude. I have known people to call back “Owinibie” (no idea if that is spelled even close to correctly), which means “black person” in Temne.

I guess all the attention is to be expected, especially in places where people are not very used to seeing white faces. I personally find it rather exhausting. I’m someone who appreciates the ability to be anonymous sometimes. Even though people are generally friendly and just curious (sometimes they are asking for money or your phone number, but usually they’re just interested in you and what you’re doing in their country), it still feels tiring to me to constantly be getting attention. There have been more than a couple of times where I have felt like an animal in a zoo – being stared at as a curiosity to see what I’ll do next. I know people that have visited here for a shorter time have found all the attention kind of amusing (some of the small kids shriek “opotho” as you drive by in such an enthusiastic way that you can’t help but smile), and I did too at first. You do end up feeling a bit like a minor celebrity. But after a while it begins to wear on you, and I think that most of the longer-term volunteers I know here feel the same way. Sometimes you just really wish you would be ignored.

Luckily for me, in Mapaki people seem to be used to seeing white people around, and it’s really different here than other places I have been. I do get the occasional “opotho” call, but mostly from small kids I don’t know. Generally, because people here know my name (my Salone name of course, which is Isata in case you forgot), when they call out greetings they are actually greeting me, not just trying to get the attention of an amusing white person. I’m sure Carolyn’s being here before me had a lot to do with that. Also, in Mapaki, I never mind the attention that I get because I like talking to people and getting to know the community and I still have my own space I can retreat to if the attention gets to be too much.

Although it can be tiring and annoying, there can be positive and interesting things about being noticed too. I hate to say this, but you often get treated better as a white person. Kind of sad, but true. For example, a friend of mine here was seen at the hospital before a whole line of other patients because she was white and the doctor thought she wouldn’t want to wait. On the interesting side of things, I have certainly had conversations with people that I never would have talked to if they hadn’t approached me because I was white. So it’s a good way to meet people and learn more about the country too.

There are certainly some specific perceptions about white people here (and of course I am, of necessity, making some mass generalizations here based on my own personal experiences). Although the perceptions are generally positive (for example, white people are often seen as both rich and experts/smart), it does give you a sense of what racist behaviour must feel like. It's unnerving to have assumptions made about you just because of the colour of your skin, even if they are more positive assumptions.

Young children often seem to be amazed or fascinated by white people. I’ve had a few very small kids (a year or two old) be quite scared of me and start to cry upon seeing me – they’d obviously never seen anyone white before. Adults/older siblings often think this is hilarious and will continue to bring the kid near me to watch it be scared, laughing all the while. Kids are also really interested in my skin or my hair, and will just stare or try to touch it.

As I said, white people are generally perceived as rich. I think that this bothers some expats, because they don’t see themselves as rich, and certainly wouldn’t be considered rich in their home country. However, compared to the majority of the population here, I am most definitely rich, both in terms of dollars in income and in what I am able to do because of that income. I have no problem feeding, housing and clothing myself and my family, and I have money for things like health and education, and even for luxuries like fun and travel. Some of the women I’ve talked to here are living on petty trading, earning maybe 20,000 or 30,000 Le per month (less than $10). Yes, per month. When I compare myself to them, I am most definitely rich.

Despite this income disparity, I haven’t had too many people ask me for money or other things here (aside from street beggars of course, which you get a lot of in any bigger city). I think this is primarily because of the work Carolyn did here in Mapaki and in the other communities where I am working in emphasizing that she was a volunteer here and didn’t have an income either. I am thankful for that, as it can be very hard to turn down requests, but it's impossible to help everyone who needs it. And the danger is that if you help one person and word gets around, others will come to you for help also. I end up feeling a little bit selfish for wanting to hang on to my money when people here have so little, but the reality is that it is impossible to help everyone that needs it. Even if you meet one request, another might come that you can’t help with. Pretty much every expat I know here has helped people in personal ways – for example, paying medical costs or school fees – and of course, we are all here volunteering, but for me, I end up feeling like there is no way I could ever really do enough.

In Canada, we are generally isolated from poverty. Yes, we see images on TV or sometimes people asking for change on the street. But being here, seeing how little many people have on a daily basis, and comparing it to what we are so lucky to have in Canada, it really makes you think about inequality in the world. And in the end, it's not about race. And it's certainly not because I’m fundamentally better or smarter in some fundamental way that I am better off in this world. It’s because of where I happened to be born. Not only the country I was born in, but the kind of family I am lucky enough to have. For me, this kind of inequality makes me feel that I have a responsibility to help those who weren’t born into such fortunate circumstances. Even if what I can do will never be “enough”, even if it only makes a small difference in someone else’s life, at least I can do something, help somehow. I guess that’s one of the things that being here has really made me think about. And for that I’m grateful.