Black Bag Medicine Men and Liberia’s Rural Health Dilemma

*Tamba’s, motorbike cuts a path through the smallest of cracks in the rainforest floor, intuitively navigating each rock and ridge, it is a course he has well-ridden.

Tamba has been crossing this region for over 14 years and knows the design of the path down to a pebble. We have been riding for 3 hours, from the nearest health facility in Konobo district, in Grand Gedeh County, Liberia. Deep within the jungle and 15 long hours from the nation’s capital by motorbike, canoe, and four-wheel drive – it is notoriously remote and among the toughest terrain to be experienced in West Africa. Tamba, is delivering a refreshment of medical supplies and to Community Health Workers in Liberia’s eastern most corner.

Community Health Workers are elected members of their village, enlisted by the Ministry of Health and partners to deliver basic life-saving treatments and facilitate referrals to health facilities for more complex cases. This unskilled workforce is a foundational component of Liberia’s Community Health Services Roadmap – a country wide strategy led by the Ministry of Health and Social Welfare as an attempt to curb preventable death in communities which are geographically isolated or far from the few health facilities scattered across the country. The intention is for Community Health Workers to address health issues of individuals in their own community through the provision of education and basic medications targeting HIV/AIDS, tuberculosis, malnutrition, diarrhea, and family planning. In a bold step towards addressing maternal child health deficits, the MOHSW has taken tentative steps towards piloting the delivery of injectable contraceptive Depo Provera. It is a much needed service to meet the family planning and health rights of women in Liberia. Given that some villages are 14 hours by foot and canoe from the nearest facility, it is not a feasible option for many women to travel to a health facility every three months to receive their injection.

Nyongbah, the community we arrive at, is one such isolated village. It is deceptive in size, though houses by count amount to roughly 25, the inhabitant’s number 350, with up to 20 residing in each mud brick single room abode. Women in Nyongbah are pregnant an average of 8 – 10 times in their lifetime, with each pregnancy their changes of death in childbirth from hemorrhage increases. In the wet season this village along with others along its axis are excised from the larger community of Ziah Town which is home to the most proximate basic health facility – during this time there is no hope of delivering their child at a hospital. Reliant on subsistence farming and the hunting of bush meat and fish from the enveloping jungle and river, young boys and men in the community are hunters, whilst women farm small cassava and banana plantations which are cut and burnt into the rainforest in small swatches.

The provision of contraception by injectable is not without controversy. There is much hesitation from the government in widening the scope of these community workers to provide a more skilled service in delivering injectable drugs – however needed they may be. This concern is heavily rooted in Liberia’s dark civil war years, in which black market medicine men (known as Black Bagger’s) supplied communities with much needed medicines and treatments when the government could not. The conflict left the health system, infrastructure and allied health staff all but decimated, with only an approximated 51 doctors remaining to serve a population of 4.2 million. After 20 long years of reconstruction toward reclaiming the Liberian health system there is now a very realistic fear within government circles that in skilling community health workers, there is a danger that these workers will abandon their posts once trained in favour of the more financially lucrative role of Black Bagging.

Despite the known significant positive impact Community Health Workers have on health indicators in rural communities the Liberian government now faces great challenge. With the highest maternal mortality rate in the world, Liberia is quite literally on the brink of a ‘do or die’ decision – skill community health workers and professionalise the voluntary workforce, or risk the widespread re-emergence of Black Bagging and  continue to be a  mainstay world leader in maternal mortality.

A woman’s right

Formerly a Black Bagger with a long history in this region Tamba in his new role is greeted warmly and with great respect in Nyongbah. On arrival to Ngongbah the community gathers in the central palava(meeting place). On the agenda today to discuss with the villagers is Ebola prevention and protection and family planning. There is much to discuss, Grand Gedeh County holds some of the worst health maternal child health indicators in Liberia. In this county, the average number of children born among reproductively-active women is 4.8, with a neonatal survival rate of 3. Almost half of reproductively-active women in Konobo have experienced the death of a child under 5, and thirty percent of women had lost an infant under the age of one. By the time a woman reaches the age of 35 in Konobo, the probability that she will have had an under-five child die is greater than fifty percent. Twenty five percent of deaths among women of childbearing age are associated with maternal complications. Without question, consistent access to family planning services can save lives.

Although it is widely reported that women in Liberia indicated a need to access family planning, obstacles such as distance from facility and cost, were often a barrier to accessing their reproductive rights to child bear by choice not by chance. Specifically in Konobo poor primary health care access is impacted by geographic factors, as residents on average live 20-40 kilometers from the Konobo Health Center—the district’s only health facility.

After reviewing some health posters and materials on the topic of Ebola, the community health worker moves onto the topic of family planning whilst Tamba and a young female community member named Cynthia* break away for a private consultation.

Following the consultation Cynthia shares that she has met in secret with Tamba to receive her routine Depo Provera injection. She continues that it is important for the women in her community, and the women of Liberia. Cynthia says that she wants to speak out against the stigma attached to family planning in the hope that women like her, especially the young, have free and continued readily available access to family planning services.

Shortly after the birth of Cynthia’s first child in 2001, Tamba made his first appearance in the village as a ‘Black Bagger’. It was not long after the visits that Cynthia began to take Depo Provera undisclosed to her husband and relatives. Such is the stigma and cultural objection attached to taking family planning, that it was not permitted for Cynthia to take contraception without the approval of her husband.

Before her injections, Cynthia had attempted taking the oral contraceptive, however living in close quarters made the pills packets difficult to hide from her husband and relatives. “Not only was it hard to make secret, it also made me so ill that I couldn’t farm our plot… people became suspicious”. It was after Cynthia recounted her first trials with the oral contraceptive that Tamba offered an alternative through Depo-Provera. As an injectable that only need be delivered 4 times yearly, it provided an option which minimised risk of being discovered by Cynthia’s husband, and above all provided Cynthia with control over her sexual and reproductive rights.

Following a government crackdown on Black Bagging some 4 years later, Tamba was forced to cease his services to the village. Cynthia, then 31, was unable to receive her quarterly shot of Depo-Provera, and as a result fell pregnant with her second child.

Tamba resumed services to the village as a Black Bagger once again and Cynthia continued on with her Depo Provera, until 2013 when Tamba began in his role as a community health supervisor and part of coincidentally part of the Depo Provera pilot project. It is under this pilot that Cynthia now receives her family planning free of charge.

Cynthia states that there is no doubt there will be suspicions and talk in the village about her private consultation today, but nonetheless she will continue taking the injectable for as long as it is available – albeit with regret that she must do so in secret. Cynthia shares, “If women in my village knew I was taking this medication to stop me from having children, they would run and tell my husband. So I take this in secret. I wish I could tell other women they can take this like me, but if I did, I might be in danger. My husband would be angry if he found out I use contraception, he wants more children, just like the other men in the village”.

When asked if other women in the village expressed a desire for birth control, Cynthia states that although many women discuss openly among themselves that they would not like more children, they would never risk taking birth control because it is seen as the man’s decision and gods will. It is evident that there is deeply entrenched male desire for more children tied to concepts of masculinity and status within the village.

Cynthia says that her husband suspects her of taking contraceptives and periodically confronts her on the matter, “When my husband asks why I am not having more children I say, ‘that is not for you to decide, that is for God to bless us with’ and then he says no more”. When asking Tamba if he is ever confronted by husbands about their wives private consultations given the suspicions around fertility, Tamba shares that this is rarely an issue, “Men don’t question me when I talk to their wives in private. Their husbands may suspect I am giving them contraceptive, but they say nothing to me. They say nothing, because the men also come to see me for other treatments that they might not want their wives to know about – in this way sometimes the secrecy works both ways”.

For women in Liberia, gender‑based power inequalities mean that many women face little choice in deciding if, when, and with whom to have sexual intercourse; whether to use contraception; if, when and how many children to have; and if and when to seek health care. A husband’s word is more often than not a deciding factor, particularly in regard to contraception and related family planning aspects such as child spacing.

Cynthia is frank about her desire for family planning, “I want less children, because I if I have less children I can spend more time with them, love them, form a bond… but with many, it’s different – you struggle to feed them, life is difficult”.

Further impressing her decision, Cynthia reflects on the high numbers of death in childbirth in the village, she has seen more than a handful of women die for maternal death in her 35 years. By taking family planning Cynthia is making an informed choice about her child spacing and reproductive health, but by extension she also is protecting herself from the potential complications and maternal mortality associated with pregnancy and childbirth. Post-partum hemorrhage, sepsis and eclampsia are among the top killers of women in childbirth in Liberia. Given that only 46 per cent of women give birth at facility with skilled birth attendant, consistent access to family planning services save lives. Despite these facts, 82 per cent of Liberian women who are within two years of giving birth continue to report an unmet need for family planning services.

The medicine man

Widely referred to as ‘medicine man’, it could be assumed that Tamba has earnt great respect in this region, perhaps a testament to his long sustained presence within the 40 odd villages in the Konobo district. But it is a complex relationship, built over 15 years and enduring his various incarnations from Black Bagger to a fully legitimised government endorsed frontline health worker and supervisor. It is not surprising that his is subsequently celebrated as a success story for Community Health Department reforms. Insisting he has given up Black Bagging, Tamba is a vocal advocate for the up-skilling of Community Health Workers to provide injectable drugs.

Whether as a result of the Ministry of Health and Social Welfare crackdown on black-marketeering or by some altruistic choice, Tamba  is now employed by an NGO under the governments franchised health care system – and he says he is taking quite the cut to his finances as a result. Although being paid most generously in comparison to most Community Health Workers and supervisors, Tamba earns a stipend of 120 US dollars a month, whilst the average NGO offers sit more commonly around the 20 US dollar amount –  with some only receiving non-monetary incentives such as as oil and flour as incentive. Tamba states that he could earn up to 250 USD per week as a Black Bagger, more than double of what he makes in 1 month in his current role.

For communities in rural Liberia, Black Baggers remain some of the most trusted individuals – more trusted than a Ministry of Health and Social Welfare which are viewed as abandoning its citizens during the war years. Although Black Baggers charged a high price for drugs and assistance during the civil war period, they were often the only option for lifesaving treatment in the most remote communities and in the absence of any other public or private healthcare options.

Tamba defends his past role stating that the majority of Black Baggers spend some months or years observing under a nurse or doctor before venturing out into the community to deliver and administer diagnosis and drugs – reiterating with emphasis that these are regions in which the very few remaining doctors and nurses, and pharmacists could be tens of miles away from communities. He goes on to state that many doctors and nurses were in support of Black Baggers, and full of hope that they may be able to assist these remote communities where they themselves could not. Doctors who saw or heard of women delivering away from hospitals and dying in childbirth, children dying from preventable disease too far from clinic – injectable family planning and immunizations delivered by these mobile traveling Black Baggers seemed like a god send – a logical short term solution to a desperate dilemma.

On asking Tamba who it is that he trained under he is aloof, and understandably so, not wanting to implicate the health professional whom he owes his unconventional career path. However, he does concede that it is true that he trained under a doctor, and he did so during Liberia’s period of conflict as a means of financially supporting himself and as a method of serving vulnerable communities.

Tamba believes his work as an honest and trusted Black Bagger in the region is why he has such deeply influential relationships and access to individuals within the community. Tamba cites his background as a Black Bagger gives him significant influence in educating service users on family planning – particularly men.

Although rural women may access contraceptive in the form of tablet or injection through the Community Health Worker program, there is significant stigma deterring women from accessing this service freely. Only a very small and secret minority of women chose to take birth control from the 3000+ catchment which Tamba oversees. As Cynthia highlighted through her story, much of the stigma springs from the in the traditionally patriarchal roots, foundational in a Liberian cultural negotiations around family. Tamba reinforces the impact of such stigma on service access, “Of the women I treat with Depo-Provera alone, I can say maybe 75 per cent are receiving the treatment in secret, that is without their husband and others knowledge… I ask them if their husband is aware, but most often they say no”.

Tamba says he works to address broader family planning issues with men specifically, “When I talk to with community it is important for me as a Community Health Worker to say that it is not always good to have a big family – you need to make sure you can provide food and keep your children healthy. I try and address the baby papa thinking, which is that it is better to have more babies”.

On why Tamba has taken the role of Community Health Worker along with his significant pay-cut he explains, “It is important for me to continue to be able to play this role… things are changing with government and ‘Black Bagging’ is stopped, but I want to continue to help villages get medicines, especially for our big problem here in Liberia, women with big belly. Too many big belly women are dying in communities, they need help”.

While the overwhelming majority of Community Health Workers related to the government program are male, Tamba states that there is an unexpected advantage in having male health workers deliver family planning services. Tamba believes that in communities where males are resistant but not staunchly opposed to family planning, he has some significant leverage as a male health worker.

Tamba says he can engage husbands around family planning, because he is a man, which he says is something that a female health worker would have less of an opening to do given the cultural barrier, “I can do this talking man to man, because it is culturally appropriate, if I was a woman, I might not be permitted to talk to the husband, or he would ignore my advice. But as a man, I have more influence, and this can be good for a woman and her child spacing or taking family planning on time.”

Making a somewhat convincing argument Tamba argues that not only delivering Depo Provera by Community Health Worker, but having that worker as a man also has its advantages, “Sometimes a woman may be missing for her injection. The next time I come to the village she can be saying to me that her husband did not let her come and that she had to work in the farm. I can go to the husband and tell him, ‘Why you not let the your woman take the medicine, you know she must have it on time or she will get big belly’, and then I can remind them of their family planning choices and why man and woman made the decision to take the medicine to stop having the big belly”.

The lesser of two evils

Several weeks after interviewing Tamba, it was found by his organisation that he had been continuing work as a Black Bagger for some months while simultaneously working as a Community Health Worker.

As a defector of the program, Tamba is the embodiment of the government’s worst fears for the Community Health Worker program. Perhaps his very example is the most realistic and honest in demonstrating the challenges of operationalising a community health worker system in a resource and capacity poor Liberia. Where a Black Bagging system has operated for so long, at such a profit, it is a valid concern that Community Health Workers once skilled may turn towards the more financially rewarding work of Black Bagging. It is debatable that this may be a necessary short and mid-term blow to accept, until the Liberian Ministry of Health and Social Welfare can provide adequate financing, governance, incentivisation, and direct quality supervision of the Community Health Worker program at all of its levels.

Whatever the debate, the Government of Liberia is on the precipice of a crucial decision around the delivery of family planning. Should the government not continue investment in Community Health Workers to extend their reach and  also reject the Depo Provera pilot and rescind its inquiry into the provision of deliverable contraceptives – remote communities will continue to suffer the burden of unwanted pregnancy and skyrocketing maternal mortality rates. For impoverished women in rural communities like those in the Konobo district of south-eastern Liberia, the suffering is aggressively disproportionate, as unintended pregnancies, pre-term birth and maternal death and disability occur with much greater frequency.

Widening the scope of what is effectively an unskilled workforce will certainly not be the answer to all of remote Liberia’s health care shortfalls. Investment in the short term is perhaps necessary to reach the most vulnerable in need of basic health services, with view to a long term goal of a strengthened Ministry of Health and Social Welfare capable of providing adequate community health resourcing and oversight.

*Names have been changed to protect the identity of those interviewed

This article was produced while on assignment with Last Mile Health.