Ivory Coast Crisis: A Field Diary

Philip James is Action Against Hunger’s Emergency Nutrition Coordinator, a job which regularly takes him to the world’s humanitarian hotspots. Follow Philip’s live updates as he reports from the border area in Liberia, where he is launching a programme to assist refugees from neighbouring Ivory Coast.

On Friday I headed out again to the border, this time to the north of the county near Karnplay. On Saturday I headed down to Beo Yoolar where our staff had started inpatient treatment for two cases. They had been admitted with severe oedema, meaning generalised swelling all over the body and were very ill. When I reached the clinic they had been there a few days and were already making a recovery, which was great to see. I was really proud of the staff who had made the best of a situation under severe resource constraints. Always good to have your faith boosted!

On Friday I headed out again to the border, this time to the north of the county near Karnplay. Loggers had decided to fell trees across the road again, so we had to wait a good hour before getting a clear path. The distributions went well during the day, this time with a lot more Liberian people than refugees so a very different feel to Buutuo. The case of a very tiny child and her condition shocked me despite me being supposedly used to these cases. She was at an advanced stage of marasmus, meaning she had lost a lot of weight to the extent that the skin was very baggy and you could see the definition of all the bones. However, the encouraging thing is that cases such as these can make remarkable recoveries with the right care. She was admitted to the therapeutic feeding centre where she is now receiving special treatment. Having mentioned this case I should also mention that there were some bouncing babies as well. Truly, some of them could have probably beaten me in an arm wrestle!

On Thursday I was due to meet a vehicle halfway between our office and Buutuo, and exchange nutrition supplies and staff. The only problem was that communication in Buutuo is non-existent, at least until we find someone coming from Ivory Coast with a spare sim card! This meant communication to our office involved radio communication to another district, which then relayed the information to Monrovia, which then called our office. This three-way communication was like a non-humorous version of Chinese whispers. To cut a long story short, it meant that the wrong items got delivered to the wrong place on the wrong day! Ah well, things will improve when we get radio in our office compound, which is coming soon!

After travelling back to Saclepea to our office I felt instantly relieved to be back! It is amazing how our relatively basic office suddenly feels luxurious compared to the conditions at the border!

As I ate dinner I heard a squealing noise coming from a box in the corner of the room. It turns out we have a new pet – a baby racoon! My colleague had found it abandoned in the refugee camp, so now we adopted it. It’s so cute and can’t fail to make you laugh as it clumsily fumbles around the room and screams until you give it milk from a small bottle!

The next day, we continued with the distributions with the help of two volunteers. These were refugees who had just arrived in Buutuo, but had worked for ACF in Ivory Coast and were invaluable in helping us screen the long lines of children and speak to the refugees in their local language.

Children under five are always the most vulnerable in a situation like this, so we have to keep a close eye on them. Screening children for malnutrition is important to identify malnourished children and provide them with the care and treatment they need to recover. By the end of the day we had finished our stint in Buutuo, screened 370 children for malnutrition, admitted 40 onto our programme and referred eight severe cases to the therapeutic centre we had set up nearby. Children with no appetite or suffering from disease need to be admitted to the therapeutic feeding centre, where they receive 24 hours care by trained staff as well as medically monitored feedings with special high-nutrition milk in order to build up their metabolisms. In addition the child will get medical treatment, including vitamins and antibiotics, to combat infections.

Children who still have an appetite and no medical complications, are admitted to the outpatient programme where they return once-a-week for special food and a medical check up to ensure that they are improving.

In the afternoon we had made it safely to Buutuo and set up a distribution point. We were targeting children aged between six months and five years old who were moderately malnourished. These children would receive a pot of nutritious food to supplement their diets with extra energy and micronutrients, the aim being to prevent them falling into a severe state of malnutrition, which is life-threatening.

I was lucky to find a room to stay in – Buutuo was packed with refugees and all the host community was already sharing the space they had. There is one motel in Buutuo and I managed to get a room, with the room next to mine housing about 5 refugees. Just as I was ready to get to bed I heard that the vehicle I had sent to follow us with a new staff member and supplies had broken down. The poor driver and staff member had to sleep in the vehicle overnight, so despite being in quite a strange environment myself, I definitely got a lot more sleep than some of my team!

We stopped off on villages on the way to Buutuo to let the village chiefs know about an upcoming distribution we would be doing with micronutrient supplements including Vitamin A and other crucial nutrients in order to prevent micro-nutrient deficiencies amongst the refugees which can undermine immunity and growth. The closer we got to the border the greater the presence of refugees. In one of the villages, Dinplay, I literally stepped out of the vehicle and was instantly surrounded by people greeting me and interested to know what ACF could provide.

Most of the people I talked to had arrived between three and four days ago, and people were still coming. We heard that in the area they had received 16,000 refugees in two nights. Even whilst we were talking to people we could hear the sounds of missile launchers just across the border – deep booms that were almost like thunder. Even though the fighting was far away and we were really just hearing the distant echoes, it made the situation more real than before. Whilst in previous weeks people had been moving out of fear of violence, now the actual fighting had started.

Monday was a challenging day this week!

The road to Buutuo is bad at the best of times, but especially after a couple of days of rain. We slipped and skated our way through the mud for three hours before finding our way ahead completely blocked. A huge truck was stuck, with about four other vehicles backed up behind with no way to pass. It was getting dark so we had no option to return to the nearest village and ask for people to help us with somewhere to sleep. With no phone or even satellite phone coverage we were well and truly in the middle of nowhere!

After an hour or so we managed to locate the village chief, who offered us his house to stay in. We all piled into what available space we could find. It was a traditional house made of sticks and mud, and contained the largest spiders I had seen for a very long time! I was just grateful I had packed my mosquito net!

We ventured into the village to look for some food and I was very happy to find out about the existence of ‘tea rooms’! These are little shops with a thermos of hot water, and serve ovaltine and bread. They make the ovaltine with condensed milk, so it’s incredibly sweet but tasted amazing on an empty stomach!

We managed to get a couple of hours sleep and trundled back into the vehicle in the early hours of the morning to continue the journey.

It's been exciting over the past few days. I’ve spent the past six days out in the field alongside the border. Therehas been a massive refugee influx – renewed fighting in Ivory Coast saw at least 25,000 refugees enter Liberia in the past week alone, probably more once final registration numbers are in. So an interesting time to visit the border... here is what happened this week.

I’ve now done six weeks in Liberia and it’s been a huge whirlwind! The programme is challenging and interesting. Whilst a lot of progress has been made there are certainly more than the fair share of logistical battles to fight when working in rural Liberia! Still, the main thing is that things are moving forwards and that an increasing number of children with malnutrition are being treated. So it’s good to focus on those big picture issues, because sometimes all you can see are the small problems that can cloud the vision of the actual impact being made. So, to end (for now), here are some of the highlights and random observations from recent days:

• The joy of receiving a bumper supply of chocolate from our Country Director!
  
  
• The realisation that I am able to take a bucket bath with cockroaches running around the bath without being too freaked out, I must be used to them. I’m just grateful there are no rats (yet).
  
  
• The discovery of a place in town that has a bar with music. Not that we’ve had much chance to try it out, but we did get one fun evening off to say goodbye to a friend who we’d worked a lot with and will miss having around.
  
  
• Having the hygiene promoter team practice their song for hours on end outside my window, singing ‘wash your hands before you eat, else you might get sick.’ Ok, so this is not a highlight necessarily, but it has been amusing to hear them rehearsing other verses and seeing how they can fit the words ‘...or else you might get diarrhoea’ into the same rhythm.
  
  
• Pilates! I may be biased, but I’m sure it’s saving my back after sleeping on a mattress that collapses under me for weeks on end!

We now have four outpatient therapeutic sites open, phew! This means that children with severe malnutrition can be treated near where they are living instead of having to be transferred to a hospital five hours away on terrible roads. The recently hired staff are doing a great job of getting stuck in and being positive despite massive resource and logistical constraints. So far, about four days into the programme, around 40 children have been admitted onto the programme. The numbers will likely escalate as the word spreads about the new facilities.

Meanwhile the water and sanitation team have been going flat-out to deliver clean water and latrines in the camp. Refugees started arriving there from last Friday, and so it’s been a busy time for everyone getting things ready in time, but the team were able to do the job and can celebrate the arrival of drinkable water!

There is a fresh influx of refugees taking place as I write –a couple of thousand or so (unofficial reports), which demonstrates the volatile situation along the border. We will see how this influences programming in the coming day or two...

We finally moved into our compound in Saclepea last Monday, which has made such a difference. It has been great to have unpacked and to have had a bit more space compared to the guesthouse. We have a plot of land which contains the office and guesthouse combined into one building and a large warehouse.

We have a wonderful cook who is looking after us well and proving that with the right skills you can make a lot of different dishes with the same ingredients. It’s amazing how some good meals improve the quality of life so much!

The office is still a bustling place, with lots of restoration work still ongoing and hardly a moment goes by without a truck pulling up, someone dropping off their CV or a workshop going on in the outside hut. But we feel established and it’s good to be able to have a base set up.

Our team has really grown this past week. Abu I already mentioned, who is the Head of Base and arranging all the logistics and administration. Then Juan arrived a week or so ago to coordinate the water and sanitation activities in the refugee camp being prepared. They are great people to work with, and also have a brilliant sense of humour which helps us on our way!

The total number of staff for the base will be around 70 once everyone is recruited. The water and sanitation team is huge, and for nutrition activities it will be around 18 to start with. So things are very different from the days when it was just me and Abu! It’s really good to have the vibe of a busy, new team.

Here are some of the small things that happened this week which made the world of difference in keeping me going:

• The little girl who is the daughter of the guesthouse owner. She is 8 months old and has the best smile!
• The offer of a cold beer and non-work chat at the end of a long day from a colleague living near our office compound.
• Fresh bread arriving from the neighbouring town!
• Emails from friends and family.
• The discovery that once in a while the local restaurant makes eggs and chips instead of pepper soup!
• The local staff we’ve recruited with their positivity and enthusiasm.
• The times I’ve been able to do some exercise...
• Any time a meal unexpectedly has vitamins and minerals in the form of fruit or vegetables – in short supply around here!

Last night was the first night in five nights that I was able to sleep without waking up at 2am for hours! I never really thought of myself as someone who got stressed easily, but everything is pointing towards me feeling the pressure! Most of the time it’s just trying to juggle recruitment, training, logistics, planning... things that would be possible with fast internet, a printer and a deputy programme manager, none of which we have as yet!

Planning the programme is a challenging task. The refugees keep moving (understandably!), people we need to train at the clinics get called away for other events, coordination between the multiple agencies is a challenge and still everything needs to have been done by yesterday! Ah well, my motto is always to do the best with the available resources and time. Sometimes you have to accept that things won’t be perfect immediately and not everyone can be happy with everything! But overall we are moving forward and I have to remind myself that the beginnings of programmes are always the trickiest parts. Things will gradually become routine!

The first day of interviews was eventful for many reasons outside the work itself. Firstly a long snake was found in the office compound. Shortly afterwards someone had decided to burn the land just outside the compound, which in the tinderbox conditions soon grew out of control. Before we knew it everyone in the office was being called to help find water and put out the fire before it reached the bamboo fence that had painstakingly been put up over the past week. Thankfully it was caught in time, but not before covering the compound in a fine layer of ash and setting several trees smouldering. The smoke must have reached a bee hive, because a huge swarm came into the office grounds and we took cover until they passed!

I can’t believe how quickly the week has gone -  it’s just been a blur of activities since coming back to Nimba! Since coming back I’ve been recruiting local staff for the nutrition activities. Lots of interviewing, learning names, figuring out how to build the team... manic times but encouraging ones too. We now have our team almost complete – six trainers to help set up the supplementary and outpatient feeding centres, one trainer to help set up an inpatient centre and six people to help with the micronutrient distribution.

 We started work immediately with the trainers, doing some refresher training for the past two days on how to manage outpatient therapeutic feeding centres. The team is great and they are experienced and enthusiastic. And I can understand what they are saying for the most part - that must mean I am slowly adapting to Liberian English!

So yes, if you asked me, I am properly stressed today! So many things to be done by yesterday, difficulties in finding qualified local staff to help and short nights! But on the upside I am now back in Monrovia to finalise funding agreements and start the process of getting the supplies in. I have a fantastic ACF team helping me in Monrovia. It’s nice to have a change of scene by coming back to the capital.

It’s amazing how much outside work has happened in the past two weeks I’ve been away as well. Three pairs of friends have got engaged, my sister has a baby girl making me a proud Uncle Phil, sad news from Uganda with the murder of an inspirational human rights activist who I had the privilege of meeting in prior years and blanket news coverage about Egypt. Lots to take in!

Over the past few days programme plans have been finalised and so the coming weeks will be seeing the activities starting, exciting and no doubt challenging times ahead!

I’ve now finished visiting all the clinic sites that we hope to use, and been busy designing the programme ACF can help local partners deliver. Needless to say that in such a situation things change all the time. Hardly a day goes by without budgets needing to change, locations of programmes changing and refugee numbers being in massive flux, plus sorting out conflicting information coming from different sources! However, we’re getting there and this is what our current programme looks like.

We’ll be working with the World Food Program to implement seven sites where children with moderate malnutrition can access food rations. Then, with UNICEF funding, we will support four sites where children with severe malnutrition can access outpatient care, and two sites where the sickest children can access inpatient nutrition care. Plans are also underway to give all children aged under two, who are the most vulnerable to malnutrition, a micronutrient and energy boost in the form of a ready-to-use food. This is to help prevent children falling into a worse nutritional status. We will also need to assess the nutritional status of the population every two months at least. All of these activities need to be implemented through local structures so that the impact is as sustainable as possible.

So there is a lot of work to do – items to procure, staff to hire, local clinic staff to train, sites to get up and running as quickly as possible. The challenge is that the refugees are spread over a massive geographic area, making it really challenging to ensure nutrition services achieve good coverage since the roads are so difficult. But things are falling into place and I’m optimistic we can meet the objectives.

Did I mention that the roads here are terrible? I think I did. But I’m going to say it again because they truly are pretty spectacular in places. There are so many bridges that consist of two large tree trunks for the wheel tracks and some slats of wood nailed on top to make a makeshift bridge. It’s fine for the smaller vehicles to cross them (though I’m glad we have experienced drivers, I wouldn’t trust my driving skills here!) but it’s a real problem for the trucks which are trying to deliver food and other supplies to the refugees. I’m just glad it’s been dry for the most-part. The roads apparently are ten times more difficult in the rainy season, so we are going to have to pre-position a lot of our nutrition supplies.

Another slight nightmare is the internet connection! So outside urgent work emails I have to be content to remain fairly cut off from updates from home. Still, this will all get better when we finish setting up our office here and get some equipment that will help us be able to communicate more easily.

I can’t remember when I last ate so much rice! The local food is mostly ‘pepper soup’ – a really spicy meat stew with white rice. We tend to have this most days, and it’s taking a while for me to adjust to the chilli content! I’m glad that mirrors don’t really exist here, I’m probably as red as a tomato after eating these pepper soups.

Over the past few days I’ve been bouncing along the roads, visiting clinics in the south run by our local partner, Equip Liberia. The locations here are even more remote, but the refugee influx is greater in this part of the county. In Buutuo, one of the places we were assessing, there were around 3,000 refugees already in the small little town, and we caught them at a time of receiving some non-food items, giving us a good opportunity to talk and listen to their stories. There was a common theme of not really knowing how long they would stay and feeling a burden on their host communities who had been patiently sharing their resources for two months now. Despite their situation they were calmly waiting for aid and politely requesting more assistance. I’m not sure I would have been so patient if I was in their position! There are now over 30,000 refugees registered in the county.

I had a funny experience today driving round a small town looking for some boiled eggs to buy for the journey. I was confused why people looked at me a bit strangely when the driver explained to them what I was looking for, and even more confused when I was advised not to buy the eggs I could clearly see in the market stalls. Eventually after a few circuits of the town my driver told me we probably wouldn’t be able to find ice here! It made me laugh a lot to think that people thought I expected to find ice in a village with no electricity in the sweltering 30 degrees plus heat! So it seems I still need to work on my Liberian English accent...

The weather here has been bizarre these past few days! When I arrived here it was the middle of the dry season – so really dusty to the extent that on some roads you have to put on full beam headlights to see through the thick layer of dust from passing vehicles, like a thick fog. But recently we’ve had some short, sharp thunder storms with huge claps of thunder and hailstorms! Instantly the roads turn into rivers with the flash flooding, weak trees fall over and travelling by road feels more like being on a skating rink due to the mud. But at least for a short time it settles the dust!

Twice in the past two days the roads have been completely blocks by massive trees. The first time it was due to people felling the tree in the wrong direction and we had to wait for someone to arrive with a chain saw to help carve a path for us. The second time it was probably due to the storm and a small army of guys with machetes helped us out!

I talked to some of the refugees over the past few days. Raymond is 23 years old and comes from the Ivory Coast. He came in mid-December after the political stalemate in his country prompted his family to leave in fear that things would turn violent. He came accompanying eight children – two of them are his and the rest are those of his brother and other family members. Everyone eats once a day, including the children he tells me. They eat rice and cassava, sometimes some bananas but no meat or fish. The host family share all the food with him. He did not personally know his host family, but they speak the same mother tongue and so they offered him hospitality. When I ask him what he thinks the most important needs are here he tells me firstly food, then medicine, clothing and shelter since they have already been with their host communities for a month.

I’ve just come back from two days of visiting the border area in the north of the county. I’ve been travelling with the International Rescue Committee who are subcontracted by the Ministry of Health to run some clinics. We want to work with the existing staff so that they can treat children suffering from acute malnutrition. Our job as ACF would be to provide technical support, mentoring and close monitoring so that after a few months the clinics have the skills and experience to maintain the programs themselves. This approach is far preferable to doing the work completely ourselves as ACF, which would be less sustainable and less empowering to the dedicated staff who work day in day out in tough conditions here. So the aim of these initial clinic rounds is to check staffing levels and to see what ACF needs to provide in terms of equipment and human resource support.

There is a huge amount of willingness from the local staff to be trained in the management of acute malnutrition, which is really encouraging. They are already stretched by having an increased number of patients from the refugee influx, but they see the importance of providing a nutritional response and are happy to extend their services. Considering most of the midwives and hospital managers barely go through a night without being woken up for some kind of emergency it’s fantastic that they are so open to additional training.

Before I came to Nimba here I was told that I might need to use a blanket at night as the temperature could drop down. Well, either the seasons have changed quickly or I am still adjusting from the UK’s winter, but it’s incredibly hot and humid here! Sometimes you take a bucket shower with cool water, step outside and feel you’re in a steam room, immediately starting sweating all over again! It’s a climate where you never really feel quite dry – always feeling slightly sticky and covered in a fine layer of dust!

The area is green, covered with jungle-type vegetation. Well, at least that what it looks like at first to my untrained eye! However, when you look closer much of the land we pass are fields belonging to local villagers - plots growing bananas, rice, cassava and sweet potatoes dotted amongst the trees, undergrowth and giant bamboo.

I am feeling a million times better having moved guesthouse to one down the road at the advice of some local expats. I am so glad I listened to them because unlike the other one this one is a) not a brothel at night b) does not have people shouting outside my window all night and c) has some space to sit and work!

I’m finally here in Nimba! The past few days I’ve literally spent half my time either in coordination meetings, or travelling to get to them! Although it can be very time-consuming, it’s a very useful time to make contacts, find out what everyone is doing, and coordinate our work. I’ve now met the local partners that we hope to work with to implement nutrition activities and we’ve planned some field trips together to the border over the coming week.  

I’m off to the border! That means heading off tomorrow for Nimba, a county in the north-east of Liberia. It shares a long border with the Ivory Coast and is the place where most of the refugees are concentrated. I’m travelling with one other colleague from ACF, a man called Abu who will help set up the base in Nimba and organise all the logistics and administration. He is from Sudan and towers above me in height, has a wonderful warm smile and sense of humour, and comes with a lot of experience. I look forward to working with Abu.

I’m still running around, getting my head around the context and planning the upcoming activities. The nice thing is that it’s now the weekend and so I have a bit more space to look around me and take in Monrovia. The local people here are very friendly. The handshake to greet people involves clicking your middle finger against the other person’s middle finger after you have shaken their hand. The handshakes seem to come in all different varieties, some having five or more separate moves, but all ending with the click! I’ll have to try this at home and see what kind of reaction I get...

Liberians speak English, so you would have thought using my mother tongue would be easy here. Well, it turns out that in the various coordination meetings I am now attending I can easily sit for a few minutes without understanding a single word! Liberian English drops a lot of syllables from words and strings the remainders together in a seamless flow. If I could just pause people and get them to insert some more consonants I’d be fine!

As my first day in Monvovia unfolded it quickly became apparent an assessment was no longer the priority – things change quickly in the humanitarian world. Results of a rapid nutrition assessment had been disseminated and it was clear that many children were at risk of acute malnutrition and that some were already severely malnourished. Initial results showed that the situation was considerably worse amongst the refugee population. So my job now shifted to helping existing staff design a programme response and to set up the programme in the field.
 
Monrovia itself is a small capital city. It sits on the West Africa coast and has a calm, laid-back feel. However, you don’t have to look far to see the scars of the civil war that ravaged the country for so many years. There is a large presence of NGOs and the UN here.

Last Sunday evening I had a phonecall from the ACF emergency response team – “we would like you to go to Liberia to lead a team to assess the humanitarian situation amongst refugees from the Ivory Coast. Do you think you could get there in 48 hours?” What followed over the next two days was a bustle of activity: getting the visa, medications, confirming flights, briefings and preparing the documents I’d need for this trip. Somehow it all got done and I found myself on the plane bound to Liberia.

Since the end of November last year, the situation had been deteriorating in Ivory Coast due to disputed election results and a flow of refugees leaving the country in fear that civil war could be reignited. As I was leaving London there were already an estimated 20,000 refugees staying in the border area in Liberia, hosted by the local community. The situation urgently needed assessing as it was not clear what the food, water, shelter and healthcare constraints were.