Wednesday, March 21, 2012

The maternal and infant mortality rate in Sierra Leone is... sobering. It's usually ranked as one of the lowest three countries in the lowest of three tiers by the UN Human Development Index.  This index measures parameters that indicate well being and ranks all countries in the world.  A Salone woman has a 1 in 21 lifetime chance of dying during pregnancy. That drops to a 1 in 8 lifetime chance of dying in childbirth. As a Physician Assistant and midwife, Lisa came to Sierra Leone hoping to make herself useful by conducting Neonatal Resuscitation Program (NRP) courses, training staff on the use of a soon to be arriving ultrasound machine, providing clinical assistance in all areas of medicine and offering on going informal continuing education discussions on various relevant medical topics.
Four midwives were identified to participate in the NRP. Three of these were from Nar Sarah clinic, Theresa, Mariama and Sarah. The fourth, Mariatu, is the sole staff and nurse of the rural Kondeya Health Care Center which has a catchment area spanning 6 -12 walking miles in any direction.  Birthing women are advised to access this health center when in labor (yep, 6 -12 bush road miles).  Naturally, I gravitated towards my former Peace Corps village to look for potential NRP participants.  Upon completion of the course, each was gifted an emergency outreach bag. The tie dyed ("gara") bags had been handmade by local women participating in the Women Against Poverty program. The items to be included were assembled stateside using donations from various entities but primarily the LaFarge Lion’s club chapter. The bag was to be used in case a midwife was contacted by a woman experiencing precipitous labor at home and the laboring Mom was unable to get to the clinic.

Digression Alert!
Of note, home birth is frowned upon in Sierra Leone and midwives can be fined if they participate in a planned home birth. Traditional Birth Attendants (TBA's); apprentice trained village women  and historically the primary midwives, were basically outlawed as birth attendants due to a World Health Organization statement where it was proclaimed that, ideally, every woman be attended by a formally  trained midwife.  Nice thought but, of course, in the bush, most women live far from clinics or hospitals.  Additionally, there  are not enough trained midwives to care for all the birthing women.  It's a dubious policy where the math equation doesn't really add up.   If the Salone Health Ministry does not support the World Health Organization goals in words or practice, they will not easily qualify for outside funding. So the TBA's were forced to stand down and the gap between pregnant women and an experienced attendant widened. A paradox resulting in the continued suffering of women and children in Salone. Of course, if I had my way, there'd be a full court press to train, supply and compensate TBA's and support a local resource and process that has existed for centuries.  It should be said that there is an effort to increase educational opportunities for aspiring midwives in order to close this gap.  Such programs take time and resources to develop properly.  Salone has much more of the former than latter of the two....

 But, back to the outreach bags...the bags included everything the midwife would need to support the birth duo in the event there was a complication such as increased bleeding or babe not breathing. The items in the bag are not easily found in Sierra Leone and, even if available, would be financially out of reach on a midwife or nurse salary. Needless to say, the bags were very well received! At the conclusion of one of the trainings, the midwives broke spontaneously into a song which repeated “Belay uman noh go die – oh” and a variation of the church song “Tehl Papa Gohd Tenki”.   It was moving and overwhelming and made me feel like our time together was meaningful and well spent. Let us hope that such combined efforts will impact the unacceptably high maternal and infant mortality rate in Sierra Leone.

As for the continuing medical education, some formal lectures were given reviewing diagnosis and treatment of common ailments such as high blood pressure, fever, diarrhea, worm infestation as well as more routine visits such as prenatal care and child development assessment. The informal sessions where we would share our understanding of various illnesses and how these illnesses were perceived through cultural filters were perhaps of the greatest value. These discussions were typically staff led and inspired by challenging medical situations we encountered during the course of the day. I was impressed and inspired by Peacemaker, Theresa, Lanasana, Mariama and Sarah and their desire to expand knowledge of clinical medicine and maximize the tools available in the clinic.

SOLAR SUITCASE - let the light shine in!
Nar Sarah Clinic, through the efforts of a variety of entities, has been using solar power since 2007. Power is available while the sun is shining but the batteries are older and can only hold the juice until about 10 or 11:00 at night. At that point, we manage in the dark and when it comes to the newly born, night is the preferred time of emergence. So, we found and the amazing, energetic Laura Satchel OB/GYN who, with the help of her solar tech husband, put together a program that provides organizations such as Nar Sarah with a carry on size suitcase loaded with 2 solar panels, LED lights bright enough to perform surgery by, headlamps, attachments to power rechargeable batteries as well as cell phones and other small recharge dependent devices. They threw in a brand spankin' new OB doppler - a tool which we desperately needed! Jim Dworschack, our friend and fellow traveler who happens to live off the grid in a house powered by solar panels, not only brought the suitcase with him in January but provided staff training and the suitcase was set up in the delivery room. Yee Haa, no more flashlight dependent births at this clinic! Headlamps freed our hands to attend to newborns and mamas with less juggling and acrobatics. So grateful. So grateful.

The arrival of the ultrasound and other equipment from overseas was delayed significantly and we were all worried that the machine would arrive after our departure. There is no functional ultrasound machine or trained personnel in all of Koinadugu district (population 265,000). The availability of such a machine would augment clinic services substantially. The machine, for the time being, would be used primarily to clarify OB related issues and I was prepared to instruct the staff on the basic use of the machine. While we focused on gaining assessment skills, we had to find equal time to discuss how the information would influence clinical decision making. My greatest fear was that, in the hands of the inexperienced, the information would not only be less than accurate but possibly used to make a decision that would compromise the Mom or newborn (inappropriate induction for "post dates" comes to mind here). We had 2 days left in Kabala when the machine arrived and, serendipitously, one of those days was prenatal day. So we lined up all willing Moms and scanned and scanned and scanned each one in turn. I was amazed at how quickly the staff became familiar with the machine. I wrote out instructions for preparing the client, scanning, interpreting the info (stressing the limitations of the machine), and machine maintenance. We all have so much gratitude for those stateside who put the container together and participated in moving the Nar Sarah Clinic closer towards offering comprehensive medical services to such a deserving community. Alhamdulillahi.
The staff all encouraged me to return so that we can carry on with these sessions. As for me, this aspect of my time in Kabala was very rewarding and fulfilling particularly in view of my first stint in Salone as a Peace Corps Volunteer which, perhaps, might be characterized by some as a series of twenty something year old distractions. And, while I’d like to think that the village of Kondeya benefited from my presence oh so long ago, I’m glad that I can now offer Salone something with a little more substance.

44 Miles and Bintumani

I left a few things undone upon my departure from Salone in ’89. I had planned to make an overland journey to Mali and travel to eastern Salone and climb West Africa's highest peak (west of Cameroon, anyway) – Mt Bintumani at a modest 6,300ft. We didn’t make it to Mali this trip either but could not escape the call of the mountain sirens and organized (such a lofty word in Salone) a trip to the Loma Mountains. Bintumani really isn’t about summiting or “bagging” a peak; like most things in life, it’s about the journey. A 44 mile journey from Kabala weaving through a dubious myriad of physical and cultural obstacles making it the most strenuous – in all ways – 44 miles I have ever traveled.

There is no real (or imagined) government oversight of an area that is considered a forest reserve and, I believe, is on its way to being designated a national park. This means that any entity between you and the mountain can feel justified in taxing you for the privilege of going there. There are only three access points to Mt Bintumani and we chose to access at the nearest point; Senakoro, 44 miles from Kabala and in the Neini Chiefdom. It seemed logical enough at the time; again, it was closest and kept us in what is mainly a Kuranko chiefdom; a tribe with whom I had lived for two years and who gave me my Africa name: Sonfon Sesay. The guidebooks try to prepare the Bintumani pilgrim for the barely navigable road conditions and lengthy series of negotiations to be undertaken for payment to village chiefs and guides and porters. With such knowledge in hand we were able to apply ourselves toward gaining as much “inside” advantage as possible to ease our way through these inevitable meetings. We were encouraged by friends to bring Moses, a Senakoro native and student in a Kabala school, who would introduce us to his Uncle, a Bintumani guide, and would be able to take us up the mountain for a reasonable fee. My friend from Kondeya, Saio, was invited to join our group.  He had traveled the back bush roads extensively but had never walked up towards the Bintumani heights.
We thought he might enjoy seeing a part of his country he had not yet experienced. He would also offer his Kuranko language skills to assist in any bargaining. A neighbor and friend of Peacemakers who was also raised in the shadow of the mountain came by the guesthouse to give us the lowdown on the walk. He suggested we come by his house the next morning as he was expecting the section chief ( chiefdoms are divided into villages and then grouped into sections) who typically collects the “kola” or offering from visitors to climb the mountain. Kola nuts are native to the area and symbolize, presumably inspired by their high caffeine content, life and vigor and are often presented to people of high rank as a sign of respect. In our case, the symbol was replaced by cold hard cash. He told us to come prepared to give the section chief a token of “small cola” and the section chief would write us a letter of introduction that included an order that no other entity should take money from us on our journey. A handy document to possess on such a journey.

So, the next morning, off Michael went to provide the kola and returned rather quickly, a bit discombobulated by the section chief, who basically said that our “small cola” was way too small and that our group would have to pay a "fee" 40 times what we offered in order to pass freely through his chiefdom. We were not prepared pay that kind of fee and I was shocked that the section chief chose to treat us as rich tourists rather than friends. Guests normally allow their hosts to run interference for them but Peacemaker and his wife Merah were both out of town and couldn't advocate for us, so I went to Old Hawa to calm down and ask her advice. Then, failing to do so, calm down that is, stormed over the the section chief’s house and in no uncertain terms made myself known. My Krio improved substantially and was flying like multicolored leaves in a high Kickapoo autumn breeze. Keep in mind, there is no formal cost to travel through any part of Salone and no formal fee to go to Bintumani. Eventually, we settled on a modified fee and a letter was provided with his stamp on it. We didn’t read the letter until we returned to collect our group only to find out, much to our surprise, that he had portrayed us as a group of travelers from the World Bank who were on their way to Senakoro to survey/assess roads. While not feeling inclined to go along with the misrepresentation, we also remembered that most folks are simply looking for the section chief’s stamp on the document. That scene unfolded over a two hour period! I can't be quite sure, but Old Hawa seemed to smirk and giggle when the scene was retold later to Peace and Merah.
It was 10:00 ish and our group of 11 including the Dworschacks, Saio and Moses assembled by the Range Rover we had rented in the still slightly cool and clear sunny morning. Ibrahim, our intrepid driver, had the vehicle petroled up and ready.

I then found out that a family of 3 would be joining us to create a 2 vehicle caravan. Phillip, Gucce and Nicholas from Belgium had driven to Kabala from Conakry where Phillip lives and works as the European Union ambassador to Guinea. The three of them were on a 2 week vacation and were traveling overland over some of the most kidney bruising roads West Africa has to offer immediately placing them pretty high on my "respectometer". Phillips well honed diplomat skills and unflappable personality would be evident by the time our adventure concluded.

 Traveling through Salone is indeed strenuous but one is equally rewarded as well. As one travels eastward, the countryside gets more deeply cut with hills rising all around.  One is in the foothills of the Loma Mountains.  Eco eye candy included far reaching views of irregularly shaped wetland rice swamps in the valley bordered by gently up sweeping forested or cultivated or burned hillsides.
The colors fade in and out depending on what is being grown; cassava here, recently cut rice stalks there, mounds of sweet potatoes scattered all about. Water snaked its way through the bottom land occasionally punctuated by a farmer tending crops, a woman washing clothes with small children playing nearby, a bird driving stand. And there’s plenty of time to enjoy the scenery; a vehicle can hope to cover about 8-10 miles an hour on such rough terrain. The experience inside the Range Rover is somewhat akin to an interminable amusement park ride where the car is either going up/down, side/side, forward/backward and galloping over rocks strewn hither and thither.

 The driver is quite engaged either shifting, accelerating or braking at all times. Ibrahim had to stop a number of times to cool the tires and wheel wells with water fetched from a nearby swamp; the sizzle of water on the vehicle was kinda sobering.

We wend our way through a series of remote villages where faces light up as soon as they recognize that strangers are coming through. Much to my children’s dismay at times, one has a rather persistent sense of being on parade in places where white faces are not seen regularly. In the Peace Corps, we referred to this as the “fishbowl effect” experienced in places like Sierra Leone if you were not of the color of majority.

We carefully approached the Seli river which is known to be passable by vehicle at this time of year. Descending a hill, two, 100 yd stretches of water divided by a sandy meridian comes into view.  To the right, the water falls over a 3 - 4 foot bank creating a bit of a mini waterfall effect surely placed there to enhance my trepidation. After that, gaze on the fast flowing deep water traveling into the distance. I waited for Ibrahim to instruct us to get out and walk across.  Only... he didn't.  He simply proceeded into the rushing water, unperturbed I might add, while I white knuckled the iron bar across the back of the seat in front of me and spent the next few minutes reviewing possible exit strategies in case we.... We made it safely across and ascended the hill on the other side to watch Phillip drive his SUV thru the same water. Before proceeding across, he got out of the car, scouted out the rapidly moving water and, I'm sure, considered ALL his options. Then with chutzpah to spare, entered the the water and rode the waves in low gear, hands at 10 and 2, knuckles white, face frozen in determination and concentration and a clear desire to live. He emerged with a smile on his face as wide as Texas. We bathed in our elation at being allowed to live another day expressed the desire to forget the old Krio proverb that "one must climb down the tree one climbs up".
Just after we resumed the trek, the section chief, with whom we had only hours previously had our little palava, pulls up as a passenger on a Honda as he was returning to his village just on this side of Senakoro. While in motion passing us, he apparently had seen Phillip and his sons and wagged his finger at me while frowning indicating that he thought I pulled one over on him. Recall that I had told him there were only 9 in our group. A true statement and made before I knew anything about Phillip and sons joining us. His Honda broke down shortly after this brief meeting and as we passed him on the road, he informed us in a tone used for disciplining children that we were to stop at his house and wait for him on his veranda. We knew the story was too long to get into on the road and so we went to his veranda and waited and waited and waited until he finally arrived about an hour later. We explained the situation to him and then Phillip paid him the “kola” at the price the chief wanted from us originally. He seemed satisfied, but for reasons that remain unclear to me, we were not dismissed to continue our journey.  The elders all gathered on the veranda and proceeded to hold another meeting in Kuranko that began to get more and more heated. Finally, after about 45 minutes, our driver Ibrahim saved the day and escorted us out so that we could continue on to Senakoro where another meeting with another chief was to take place on another veranda. It was 5:00 pm and the day was far from over….
The town of Senakoro is, simply put, gorgeous. It has all the requisite features of what one might consider an idyllic Salone village; the layout is gentle, houses thatched, animal and kids running about, mountains rising in the distance – AAAHHHH. Little time to enjoy as it was getting late and the West African sun doesn’t like to stay around past 7:00. So we needed to check in with the chief and make arrangements for sleep. The chief was very kind and we presented our offering of “kola”. We also presented our letter from the section chief. He accepted the offering and offered the school house for lodging. He requested that we return to his veranda to discuss arrangements for guides and porters as soon as we had eaten and settled in.

So, we made ourselves at home in the small but adequate school rooms and arranged for someone to cook rice and groundnut stew for supper. The teachers came to the school requesting that we pay them for the accommodations. In Kuranko tradition, if you pay the village chief and he assigns you a place to rest, there is no further obligation on your part and he will compensate the villager accordingly. I pointed this out nicely to the teachers and they left looking disappointed if not a bit miffed. We had an awesome meal and set up hammocks and beds, then made our way back to the chief’s veranda for the next round of negotiations. The chief opened with his sentiment that our “kola” was meager. I, admittedly, was feeling less than patient at this point having heard this from so many people in one day. I also knew that each had been given in excess of what is considered a normal fee so was exasperated by this constant squeezing for more money. The chief backed off rather quickly and we were told later that his advisors had asked him to try and get more money from us. We then found out that trekkers are not allowed to choose their own guides or porters; apparently there is a rotation system among the village clans to make sure every clan gets an opportunity to benefit from visitors to the mountain. This, unfortunately, means that anyone with knowledge of the path is considered a “guide” and no other skill enters into the equation. We had heard of one guide who simply left his group at frequent intervals to go hunt. The hikers were forced to remain at trail crossroads until he showed up again. We indicated what we would be willing to pay a guide and two porters (I was negotiating on Phillip's behalf for the porters he needed) only to find out that the chief would not involve himself in negotiating the fee for services. I’m not sure why it took an hour on his veranda to learn that he would select the guide and porters but wouldn't involve himself in the negotiations for payment.  Hoping to expedite departure in the am, we asked the chief to relay the fee we would be paying to the proposed guide and porters and tell them that we wouldn’t be negotiating the fee any further in the am. But the morning had its own agenda…the guide and porters were selected but, much to our dismay though not surprise, would not agree to go based on the pay we offered (10 times what an unskilled worker could expect to be paid for a day of work in Salone). Another round of negotiations ensued and Phillip ended up giving the porters a bit more so we could leave sooner. We paid them half the agreed upon sum with the balance to be paid on our return in a few days. Finally, oh finally, by 9:00 we had packs on and could start the walk up from 1200 ft to 4500 ft over the next 5 hrs. A record departure time out of Senakoro according to other trekkers!

Now came the physically demanding part which, in retrospect, was not nearly as strenuous as navigating through the events of the day before. We were rewarded with rainforest flora but didn’t see too much in the fauna department. We could hear lots of birds with calls that were strange and exotic. There were three distinct hand over hand scramble climbs. We were a bit shy on water at one point and Saio, our constant poyo (palm wine) connection, was hauling up a gallon of the stuff and swilling it back at frequent intervals to give himself energy. Michael found himself joining in and the two of them seemed to ascend the steep incline effortlessly and without care.

At last we reached the top of the hill near camp 2 and what a site! Savanna like mountain vistas dominated by grassy hillsides punctuated by rocks and linked by web like buffalo paths. A fresh water stream near its spring head flowed adjacent to the camp and a small waterfall only a short walk away. Kai and Mattias each felt compelled to head out and up and explore the countryside for a while before settling in. We ate a simple meal of spaghetti and tomato sauce drank a Vimto spiked with some sort of packet gin that Linda and I had discovered in Kabala and went to bed. The Dworschack’s had brought hammocks to sleep in and we had 2 thin foam pads and blankets. We snuggled beneath and in between trees that both canopied overhead and snaked underneath us. The moon rose full in a clear sky boding nicely for good viewing the next day. Then the wind began to pick up, gently at first then much more vigorously, and move the canopy and branches and trunks and, to our amazement, the roots underneath us themselves! It was a tree root massage and the sounds of moving, living wood creaking up and down in cadence and tone speaking like the Ents of Tolkien's world. Magical.  Unforgettable.

 The next morning dawned neatly and we found ourselves covered with a nature’s blanket of twigs and leaves. Coffee and a bite of bread and groundnut paste and we were ready. But the guide and porters had been busy talking amongst themselves and decided the money we were paying them wasn’t enough to stay a second night. They claimed not to have known that we were to take two nights in the bush. An interesting claim since they had negotiated a higher fee BECAUSE we were staying a second night. So, after pointing this out, they backed down but asked us to consider descending to camp 1 that day so they could get to their fields sooner the following day.

And so we began our walk to Bintumani’s summit, a 2,000 ft ascent over about 3 hrs or so. We were dazzled and amazed by the unique and stark beauty of the area. Not a village to be seen until we reached the summit. I loved watching Saio take it all in and cherish the magnitude of having the opportunity to climb the peak he had only heard about until then. Bintumani was no longer just a name to him, it was an experience and I felt so blessed that we could all share it together.

We walked over volcanic rock, then quartz fields and through areas with rocks standing in impossible positions stretching one’s imagination about how such things come to be. We rested on the last mound of a hill before starting the Very Steep ascent to the summit. The last 20 yds was a vertical scramble which opens to a plateau and the obvious SUMMIT! We gravitated to The Cairn and placed our rock along with those from others in the Bintumani Club.

We created a special cairn for our dear friend, Rick LaMartina who passed away gracefully shortly before we left for Africa. He had always liked to say to us that we “lived large”. Well, Rick, it could be said that you lived equally large from an inner space.

Kai thought we spent an awful lot of time and effort to only remain at the top for 45 minutes or so. He was clearly enjoying the sense of accomplishment but there was camp 1 to descend to and the day was moving on. So, reluctantly but full of the experience, we turned around and began the careful descent picking our way down and trying to find the surest footing possible. In this way we moved all the way to camp 1 and arrived with enough daylight to get supper on in a timely fashion. The group was tired and sunburned but enjoyed an evening leaning against a big old cotton tree knowing there was a shorter hike waiting for us in the morning  (tho no one was particularly looking forward to the 5 – 6 hr galloping ride back to Kabala). That night, the guide and porters requested in no uncertain terms that we head back at the crack of dawn so they could get to their fields. We agreed to not dilly dally in the morning without actually agreeing to the “crack of dawn” bit. So another magical, breezy night and blanket full of twigs and leaves and up we got to coffee up and eat a bite before leaving. Unfortunately, Mattias had a touch of intestinal something or other and was feeling less than energetic. He toughed it out as one must do under such circumstances.

 As we readied our packs to depart, a single gunshot ripped through the air and a few moments later, a hunter walked up with a dead monkey. The guide and porters were pretty excited and announced that we could take off our packs because they wanted to gut, skin, and cook the monkey meat. This proposed delay didn’t go over too well with us as a group. We announced that we were leaving and that if they didn’t feel like completing their end of the agreed upon service, we didn’t feel obligated to pay them the balance. The monkey was gutted and divided into portions post haste and we were on our way.

We entered the area of swamp farms and I was floored by the amount of land under cultivation for groundnuts (peanuts). The planted areas were a stunning blanket of green and covered acres of land with oil palm, mango, orange tress interspersed here and there. We took a short break and proceeded to pay the balance to the guide and porters before reaching Senakoro.  But, much to our amazement, they maintained we hadn’t paid them the first half before leaving Senakoro two days ago! It was a last ditch effort to cow us into paying more money and, at this point, even Saio had become utterly disgusted with the way we were being treated. He had to maintain a balance between his relationship with us and his fellow tribe members and we respected his line walking and never asked him to negotiate on our behalf. We didn’t bless this last interaction with a response and simply started walking toward the village which was now within about ½ mile. We bid the chief a quick goodbye and left as soon as we could get Ibrahim in the Range Rover.
The drive back to Kabala was interesting and strenuous in all the same ways as the ride to Senakoro sans the veranda sitting and constant haggling.  Oh, and the river was waiting for us, too.  We passed freely through all.
So much beauty, so much pain.

Addendum:  Indeed, I was clearly frustrated by the need to constantly negotiate and renegotiate fees.  This aspect of Salone is new to me.  Back in the day, one would need to get to Senakoro, give kola to the chief, find a guide and climb Bintumani.  Done.  I understand that the villages on the Senakoro line are feuding over who gets to collect fees from trekkers and this has sparked a bit of a free for all whereby each village will try to exact a fee from travelers passing through. No doubt that this development is driven by people living below subsistence level and who have increasingly seen the visitors as a potential source of income.  The unfortunate part is that as the reports of experiences like ours get into guidebooks or on the internet, informed would be trekkers will avoid Senakoro as an access point to Bintumani.  We encouraged the Paramount Chief to review this process and consider standardizing fees then alert the guidebook authors when he has done so.  We'll see and let's hope betta go deh for all.

Nar Sarah Clinic
The Nar Sarah Clinic headlines a number of projects all of which are designed to meet the needs of the greater Kabala/Koinadugu district community and provide income to support the clinic financially. The remaining funds needed to keep the clinic afloat are obtained through donations and the efforts of the Nar Sarah Clinic board. The board is comprised primarily of men and women who have deep connections to Sierra Leone either as nationals living abroad or volunteers who lived in the country at intervals over the years. These are clearly dedicated people who have invested scads of time and energy into creating a web of services that is largely run by Sierra Leoneans for Sierra Leoneans. This is the meat of international development; having nationals on the front line making decisions that are culturally specific, culturally relevant…and it seems to be working nicely. Progress is steady despite all the usual obstacles and uncertainties present in a developing country.

Oil Palm Project
The oil palm project was designed to connect the clinic with a local community whereby the village would  manage the plantation and the clinic would benefit from the proceeds. The Bendugu village chief, a village about 8 miles from Kabala, donated land to create an oil palm plantation and a paid manager was selected from the community. The first seedlings were planted 3 yrs ago and each year more have been added. Soon, the trees will be bearing the “banga” or oil palm seeds from which the oil can be extracted. The oil, a maligned substance in the States as it's been implicated in contributing mercilessly to the ever growing obesity rate, paradoxically, is an essential element of the austere Salone diet providing vitamins and much needed saturated fat. It’s also a nice cash crop that, with good maintenance, simply keeps on giving – for decades!

Extracting the oil is a messy, intensive process which involves cutting down the seed bunches nestled in between the palm branches, boiling them in water to release the seeds, removing the seeds by carefully picking between the spiny pods (think blackberry pickin’ pain here), mashing the seeds in a large mortar using a pestle, then returning the orange, fibrous material back to the kettle to bring to a boil again until the water steams off leaving mostly oil. The thick, pumpkin colored oil is then skimmed off, bottled and stored.  Nothing is left unused in Salone and the residue is used to make soap.

Michael and I had a chance to visit the Bendugu oil palm plantation giving me my first opportunity to ride a Honda XL in Africa again. For the Peace Corps agriculture volunteer, these Hondas were how we got around to the various bush farms. Peace Corps replaced the Hondas with mountain bikes shortly after I completed my 2 yrs. I believe this decision had something to do with volunteers using them to engage in non-Peace Corps related activities and the inherent safety issues of bush motocross. For those of us who lived and loved the challenges of off the grid riding, this policy change was met with a heavy nostalgic sigh. But now, here I was getting ready to ride into the bush once again, with a husband passenger no less! I should note that I was gifted a Honda XL to play with on our rural Wisconsin farm about 7 yrs ago. My motorcycle skills have not suffered from the distance between me and my younger self.

So off to Bendugu we rode with Robert Jarawa, our program manager, in the lead and Peacemaker behind us. My initial, but mild trepidation, gave way rather quickly to the exhilaration one experiences riding on a road that requires your complete attention. After a short while we came to a creek crossing where we were to ride into the dark water and continue partly submerged on rocks you could only feel for about 10 -15 yards. One is supposed to do this… willingly. Okay, so, back in the day, these water crossings were common and my least favorite Honda activity. I bagged and, somewhat shamefully, asked Robert to ride the Honda across for me. Michael and I walked across. Robert jigged and jagged and galloped over and through and met us on the other side. He handed me the Honda keys and said that he expected me to ride through the water on the way back (here’s “the tree you climb up is the tree you must climb down” proverb at work again – dang!).

The oil palm plantation was a pleasure to tour – so much work and collective effort! Remember, there is no mechanization in most of Salone; any/all rural farm work is done by hand.

Cultivating acres of anything is phenomenally labor intensive the manager was able to keep acres and acres of farmland brushed, planted, and protected with a firebreak with only a few helpers. Soon there will be profits to be made that will be directed towards sustaining the project and the balance will go to support clinic services. On a side note, we also got to see how farmers make beehive boxes and attach them high in the crook of a tree branch. It’s hard to imagine how the honey is harvested without the use of nets and coveralls. A farmer simply smokes ‘em out and collects what he can get at. Honey is expensive, nutritious and would make a nice cash crop. Might be another project to consider as it would need very little start up cash to cover gear, boxes, smokers.… 

So back towards Kabala and, indeed, the wide, dark, rushing water, rocky bottom creek was waiting for me. Michael crossed on foot so he wouldn’t “muddy the waters” (smirk) and could document the occasion. So into the water I drove, low gear, steady speed and galloped my way to the other side without hitting any unforeseen deep pocket or large rock or hippo (just kidding). Sweet relief! And it wasn’t nearly as unstable on the bottom as I had anticipated.   Heavy sigh but big smile on my face and back to Kabala we rode zigging this way and that to avoid obstacles and “find the chutes” in the same way one might navigate white water in a  canoe/kayak.

Guesthouse Plumbing
One of the projects identified by the staff was to plumb in the guesthouse. The guesthouse is just that, a place to stay for program volunteers and visitors. However, some visitors would clearly be more comfortable if they had a toilet to flush and a working
shower. The guesthouse has a bathroom but it hadn’t been plumbed in yet. We had simply been refilling a 50 gallon tank with water from Peacemaker’s well in order to take bucket baths and flush the toilet. Robert and Michael put together an equipment list and made a plan.

Robert navigated through the Salone network of plumbing supplies having to travel all the way to Freetown – 250 miles away - and haggle over prices and supplies then get them transported to Kabala. In the usual Robert Jarawa fashion, he did this with grace and reserve and diplomacy. When the Dworschacks arrived, we were all set to begin a project we thought would take up to a week. Neighborhood boys saw the work being done and jumped in alongside our kids and volunteered their time to dig the 50 – 75 yard trench from the clinic to guesthouse breaking up very rocky, densely packed soil. Well, with such efforts and a few blisters, it took two days! A few quirks needed to be worked out over the next week but the project was successful and, we hope, will result in more volunteers willing to visit and contribute to the Nar Sarah community.

Time to Go
The day of our departure crept closer and closer. We felt the weight of leaving increasingly as the week progressed. We were so pleased the medical supplies container had arrived in time to conduct the ultrasound training and sort through the items. These activities consumed our last two days.
We took time to say good bye to all of what I call our “greetees”, those people who had become accustomed to seeing us walk through Kabala from guesthouse to market. Our special friends, those who had businesses we had patronized regularly and got to know, these were the toughest farewells. Salone is a land of uncertainty, life is inherently tenuous, and there is no guarantee that even if we can get back, our friends will be alive to greet us.

Goodbyes have a different tenor and tone altogether. Our goodbyes in the States are so casual comparatively. We can only hope. My goodbye to Kondeya, well, too challenging to describe fully. Let it be said that we hope to share space once again. I rode there and back with Peacemaker’s Honda XL, weaving my way over hill and dale and around ruts and rocks remembering the road as if I had never left.  Very fitting.

The Nar Sarah Clinic staff hosted a farewell gathering the night before we left. Our friends gathered around in the guesthouse for a sweet and tearful ceremony where we exchanged speeches dripping with mutual respect, friendship, acknowledgement of our various talents, and desire to continue the relationship forged over the last few months. Robert Jarawa, whom I would vote for if he were to run for president, gave a very special speech where he afforded us way too much credit and himself too little for the progress made in the clinic, guesthouse and various programs.

The morning of our departure arrived.  We had arranged transport on the government bus to Freetown, necessitating another pre dawn walk through the quiet streets of Kabala to the motor park with our luggage. We were escorted by Peacemaker, Lansanah, Mariama and, before leaving the guesthouse, had some tearful goodbyes with Merah and Old Hawa.

Ah, old Hawa.  Sigh.  Old Hawa had been glancing at me all week in the same way one gazes upon a person who is moments from departing. I had been keeping an eye on her medically and tuned up her medications.  With a few minor adjustments, some of her underlying conditions were better controlled, and fortunately, in her case, this translated into feeling better than ever.   She was feeling the impending loss of her personal medical provider and friend. For my part, she is my wise woman elder, and leaving her was equally difficult. It was dark and our eyes were leaking silently and I turned away from her.   She slowly walked towards her prayer mat, faced Mecca, and readied herself for morning prayers.

Theresa and young Hawa were also coming to Freetown and so we all departed amidst the crowing roosters and other passengers for another 5 – 6 hour ride to Freetown arriving in the heat of the day. We had a quick bus ride to Juba Hill and then a motorcycle taxi to Dorcas Kamanda’s Freetown house for the next few days. There isn’t too much to share about Freetown except that it’s congested, busy, noisy, dirty and not easy to get around whether you are in your own car or on a Honda or on a bus. We went to Tokeh beach for the day with the Dworschacks.  We departed for Freetown as our flight was the next day and left them there to enjoy a few overnights on the beach, and indeed they did!  They had a magical 3 days sleeping in their hammocks between palm trees on the practically deserted beach, eating fresh fish and lobster and even snorkeling!
Hawa stayed by our side during this final time in Freetown. It was a nice, relaxing transition spent in the presence of a new friend. The day of our departure was spent eating our last cassava and rice, doing a bit of souvenir shopping and enjoying the hour long ferry ride across the bay to Lungi airport. Everything went pretty smoothly. Our goodbye to Hawa was, bittersweet; so glad to know her, so sad to leave her. We have a business arrangement where I agreed to bring some of her tie dye (gara) cloth back to the States to sell so that she could keep her business afloat and make a living. If it goes well, perhaps we can continue the arrangement….

The plane lifted effortlessly in the cool night air above the smoke, haze, kerosene lights and friends whom we had grown to care for over the last few months and headed north to England where we would spend the next week.

England: bell ringing, cathedrals, thatched roofs, narrow roads, mystical stones
We had the great fortune of staying in the English countryside with an Arvigo Therapy friends of mine Hilary and Kengo. They offered us a peaceful place to rest and transition while introducing us to some of England’s famous historical sites. We learned about the culture and history of bell ringers;

Kengo, being a newer and enthusiastic bell ringer convert, had the inside scoop. Timing, precision, coordination and solidarity with fellow ringers communing in a historical activity seems to fill him up.

Our tour guides brought us to gaze upon the hill of Silbury, mystical stones of Avery, walk in the countryside woodland, and Salisbury cathedral. 

 The Cathedral experience was complete with a guided tour by a retired, wheezy, cathedral history enthusiast and an unexpected chance to watch a choir rehearsal practice.

And, let’s not forget the glorious food!
The daily fare was filled with variety and created with mindful preparation and I left inspired about cheese boards and desserts with decadent toppings for berry crumbles. The lovely scenery is a testament to the commitment to maintain beauty through zoning and support of local businesses and not cave to box company corporations which blight our landscape ever increasingly here in the States.
We spent the last 3 days exploring London’s offerings doing the usual tour circle including The Tower of London, London Eye, walk to Westminster and Buckingham and, the best by far, Greenwich Royal Observatory.

We made sure we ate our way through proper English breakfasts, pie and mash  (no eel jelly, though!), stews and such. Michael, a micro brewer in the making, enjoyed sampling the various ales and stouts made by local breweries. I rediscovered Irish coffee – yum!

So another departure came and we made our way effortlessly through the largely predictable London tube system to Heathrow airport and boarded our flight that would get us a bit closer to farm and family. My sister Jana picked us up and whisked us to her home where we continued to indulge in hot water, food and family. The Midwestern winter had been uncharacteristically mild with little snow, however, the morning we were to return to the farm – yep, a heavy, beautiful snow had fallen and blanketed the ground. It was too beautiful a sight to feel inconvenienced in any way. In fact, Sierra Leone has a way of resetting one’s tolerance for or even definition of “inconvenience”.

A few final thoughts:
Nar Sarah Clinic is an inspiring model of how a development organization can work effectively within a particular cultural system to support efforts that are being informed primarily from within. While I don’t work full time within international development, I do know there are plenty of models out there that are best avoided. These are organizations that are not in touch with the needs of the community and are interested in generating numbers to justify funding. While this is a gross over generalization, sadly, it's been my experience  in developing countries where I have worked medically. Nar Sarah Clinic has relatively little overhead and donated dollars translate into augmenting direct patient care. The staff, administration and board  have a unified vision and clear desire to expand clinic services to include inpatient care and surgical capability and are working hard to do so.
What attracted me additionally was the fact that the organization is as dedicated to building relationships as it is to staying economically afloat. Volunteers like us, an entire family, were welcomed enthusiastically into the fold.  Most NGO's I have contacted over the years were quick to say they'd love to have me involved but my family would need to stay at home.  Not so with Nar Sarah - we were accepted and encouraged as a team.  They acknowledged that it's important to build global connections and doing this through our youth is key.   People first and last and the money will take care of itself.      Refreshing!

If you feel you’d like to get involved with this organization – visit the SEED website, look around and send an email to get more information.