Treating the Victims in Liberia's Civil War

Dr. Andrew Schechtman, a family practice physician in San Jose, California, has spent a lot of the last ten years on the front lines of developing country hot spots. Working as a volunteer with the French-based charity Doctors Without Borders (Medecins Sans Frontieres), he has treated the sick and wounded in Uganda, in Guatemala, and most recently, served two stints as a volunteer doctor in war-torn Liberia. Schechtman's Liberian diaries have been something of an international sensation. They were reprinted by the BBC and were widely quoted by publications such as U.S. News and World Report, National Geographic, and the Christian Science Monitor. He recounted his Liberian experiences to an appreciative audience in a conference room in UCLA's Bunche Hall January 16. His meeting was cosponsored by the James S. Coleman Center for African Studies and Doctors Without Borders.

In August 2002, Doctors Without Borders, commonly referred to by its French initials, MSF, asked Dr. Schechtman to take a volunteer position in the town of Harper in southeast Liberia, at the height of the civil war between then-President Charles Taylor and the insurgent Liberians United for Reconciliation and Democracy (LURD). "At the time," Schechtman recalled, "I didn't know where Liberia was." He learned quickly. Liberia had been formed as a nation by some 20,000 former American slaves repatriated to Africa by the American Colonization Society, which Schechtman described as "an interesting group formed of Quakers who didn't think freed slaves would have equal opportunities in the United States, combined with slaveholders who were afraid that freed slaves in the United States would be at risk of uniting and forming an uprising." Today Liberia has a population of about three million people.

The recent civil wars are rooted in a historic clash between the Americanized returnees and the much larger indigeneous population. The American Liberians dominated the country until 1980, when President William R. Tolbert, Jr., was assassinated by a figure from the indigeneous population, Samuel K. Doe.

The Rise and Fall of Charles Taylor

Charles Taylor, who in turn led a revolt against Doe, was of mixed indigeneous and American-Liberian stock and firmly in the Americanized camp. He was educated in the United States, where he served a prison term for embezzlement, returning to Liberia and launching a rebel movement in 1989. His forces quickly succeeded in killing Samuel Doe. However, despite capturing much of the countryside, which he modestly renamed Taylorland, failed in eight years of bloody struggle to take the capital at Monrovia. Taylor did finally and disastrously come to the head of the Liberian state by winning the presidency in a demoralized election in 1997. But his repressive rule only set the stage for a new antigoverment uprising, by the LURD. Taylor was forced into exile in Nigeria in August 2003.

Dr. Schechtman saw no good coming out of Taylor's presidency: "By this time all of the middle class from Liberia, all of the educated people, all of the professionals, had left. Political opposition was persecuted, professionals weren't given opportunities to apply their trades freely, and Taylor really had a stranglehold on the economy. So there was a massive brain drain in Liberia. The entire infrastructure that had been developed, like electricity and running water, was thoroughly destroyed. Most of the country was run by strongmen from local military units."

Schectman arrived in Liberia in August 2002. "Harper," he said, "was absolutely gorgeous." Before the war it had been a beach-front resort town. It was "a place with hotels and restaurants where people would go to vacation, until the time of the civil war. Gorgeous beaches, beautiful buildings, a busy fishing industry catching tuna and lobster."

The town changed hands many times between Taylor's faction and the rebel groups. Dr. Schechtman said the people of Harper were often beaten, robbed, raped, or killed when different armies captured it. "The local civilians learned that the only thing they could do for their own safety was to flee across the border into Ivory Coast when the town was being attacked. By 1994, most of the people had fled from Harper and were living as refugees in Ivory Coast across the border."

By 2002 when Schechtman first saw it, the town was fairly well in ruins. "The water system was useless, its houses had been stripped, metal roofing was sold as scrap or taken somewhere else, and the fishing fleet was fully destroyed. Fishing continued, but with dugout canoes with wooden paddles."

Working at the J J Dossen Memorial Hospital

Schechtman was one of four international volunteers working with MSF in Harper. There were two doctors, one nurse, and one logistician. "A truly international group, we were American, French, German, and Afghani." They worked at the J J Dossen Memorial Hospital, one of only four hospitals in Liberia. The regular staff of the hospital included 100 local workers but only one surgeon, eight physician assistants, and nine trained nurses. There were at that time only 30 doctors in the whole country. The local surgeon left shortly after Schechtman arrived and he took over much of the surgery in the hospital, although he had not done much operating since his days as a resident just after medical school. They also confronted a bevy of tropical diseases.

"We were doing some novel work with malaria in Harper," he added. "Malaria is one of the most important infectious diseases in the developing world, killing more than a million children every year." Some 80 percent of the mosquitoes that spread the disease have become resistant to Chloroquine, the principal drug used to treat malaria. "Yet it still remains the number one drug used by African governments because of its low cost."

The typical practice in the developing world, Schechtman said, is to treat malaria based on symptoms only. If somebody comes in with fever and perhaps an enlarged spleen, they will be treated for malaria. "When we started introducing new drugs that are a little more expensive, treating in a shotgun fashion became very expensive. So we introduced point-of-care testing, with a test that could be done in fifteen minutes and making the diagnosis of malaria 99 percent accurate.

"We also introduced treatment for malaria with artemisinin-based drugs. Artemisinin- based drugs are derived from a Chinese herb that was discovered more than 3,000 years ago, lost to science, and rediscovered in an archaeological dig in the 1970s." The herb is Artemisia annua, known in the United States as sweet Annie or annual wormwood and in China as qinghao. "It is now the most effective drug for malaria in the world," Schechtman reported.

Only a couple of months after Dr. Schechtman arrived in Harper, civil war broke out in neighboring Ivory Coast, which had been the source of his group's medical supplies and home to some 25,000 refugees from Harper. After that the Doctors Without Borders staff had to travel two days by road to Liberia's capital, Monrovia, in order to stock up.

"In February 2003, I had finished my 6-month project in Harper and I absolutely loved it. I was doing great medical work, taking care of people who probably would have died if I wasn't there, and I really felt that I was part of this community, this town of five or ten thousand people. I would walk down the streets and the children would run after me screaming 'Dr. Andrew, Dr. Andrew,' and it was just a great feeling and I loved the work. So I signed up for another six months."

Invasions, Evacuations, and IDP Camps

Schechtman returned home to make preparations for his next trip to Liberia. While he was in the United States, rebels from Ivory Coast invaded Liberia, capturing the town of Zwedru and taking over the five-thousand person refugee camp MSF had set up. In addition, two Doctors Without Borders volunteers and two volunteers from another aid organization were captured and held for three days before being released. "It was a nervous time," Schechtman recalled.

Then the rebels captured Harper. MSF evacuated their international staff from the project in a small plane that landed on an abandoned runway. "Our hundred-plus local staff  were essentially on their own for finding their way out. Miss Miller, the head nurse of our hospital, who was a Liberian nurse for more than twenty years, and my physician assistants, were forced to pack everything onto their backs and run through the jungle across the river to become refugees in Ivory Coast. When my month leave in March ended and I was ready to come back to Liberia, the project I had come to love was no longer there."

Internal Refugees in Bong County

Dr. Schechtman found a new project in Bong County in the east central part of the country. Fighting in the north by the LURD (Liberians United for Reconciliation and Democracy) rebels had displaced thousands, many of whom found their way to camps in Bong County. They were referred to cryptically as IDPs, short for internally displaced people. Much of Dr. Schechtman's work took place inside these IDP camps.

IDPs are essentially refugees, but they don't have refugee status because they haven't crossed an international boundary. Doctors Without Borders provided drinking water and water for cooking for fifty thousand people in three camps in Bong County, supplying more than half a million liters of water per day.

Schechtman commented, "It sounds like a lot of water and it was a lot of work for our logistics team, but it only came out to be ten liters of water per person per day. An average in the United States is at least two-hundred liters of water per person per day."

Because of the large volume of patients, Schechtman supervised a team of physician assistants and nurses who saw patients directly. "My job was mostly to consult with them on difficult cases, help them with the management of the patients, answer questions, teach, and train them."

The five physician assistants would see at least four-hundred patients a day, working out to about eighty each. In the United States, Schechtman said, the average is closer to twenty or twenty-five.

Eighty percent of the women Dr. Schechtman saw had gone through a ceremony around the time of puberty which included ritual scarification as well as female genital mutilation where the clitoris is removed.

Displaced People Evacuated

"The security situation was always fragile and changing quickly," Schechtman said. "When there was fighting, one of our three IDP camps was evacuated and all of the people took to the road again carrying what they could on their backs, with their children, usually some cooking supplies, some clothing, if they had any food."

When internally displaced people arrived in a new site assigned by the Liberian government, they usually were forced to fend for themselves upon arrival. Schechtman described the way in which makeshift houses were built in these temporary camps. "One of my colleagues called these houses mushrooms because they seemed to spring up anywhere without any sort of civil planning or thought about where their water or sanitation would be located."

Exacerbating the medical situation, many of the inhabitants of the IDP camps got their drinking water from holes in the ground. As Schechtman explained, sometimes this would have been fine except for the fact that other inhabitants would pass waste on the same ground used to gather drinking water, leading to large-scale outbreaks of diseases like cholera.

"People lose so much fluid from cholera that they can die within six hours from dehydration. It's a very easy disease to treat in some ways because just by replacing the lost fluid they will survive."

To add to an already chaotic situation, Schechtman said, because of security concerns the Doctors Without Borders staff was forced to evacuate the IDP camp in June 2003 and return to Monrovia.

"Monrovia is a big city, more than a million people. Its infrastructure was also destroyed. There's no electricity or running water. With the LURD rebels just outside the capital, Charles Taylor finally agreed to go to the peace talks in Ghana."

As soon as Taylor arrived there he was indicted for war crimes for his responsibility in the atrocities during the fighting in Liberia and also for his support for rebels carrying out incursions into Sierra Leone. Taylor then fled back to Monrovia. With no hope left for the peace talks to succeed, Schechtman said, Taylor's LURD opponents decided to make their move. "Within twenty-four hours, these rebels mounted a major offensive into the city in what the Liberians call 'World War I' because of its devastation."

Doctors Evacuate

The Doctors Without Borders team, having already pulled out of all their projects in other parts of the country and not having any active projects in Monrovia, decided to evacuate until the security situation stabilized.

"Our team withdrew to the European Union's compound, where we hid behind high walls with barbed wire for three days while the evacuation was planned. Meanwhile outside the walls, gunfire and explosions went on." Eventually French commandos arrived and escorted the MSF team by helicopter to a French warship. There followed a three-day journey by water to Abidjan, capital of Ivory Coast. There they were faced with yet another difficult decision.

"Knowing what we did about how much the Liberian people needed us, how little access to medical care they had when we weren't there, but also knowing how dangerous the situation had become, do we go back or do we find somewhere safer to work?" They were told to each decide for themselves what to do, there would be no group decision. "We all decided to go back."

Back in the Field: At the Samuel K. Doe Stadium

"Having no project, we came up with a new one at Samuel K. Doe Stadium on the outskirts of Monrovia. Samuel K. Doe stadium was an impressive soccer stadium that used to hold big matches but hasn't been used for much during thirteen years of civil war."

At the time MSF set up their facilities in the stadium, it was being used as a place of shelter for more than twenty-thousand internally displaced people. "Our work there involved setting up an outpatient clinic where we saw more than four hundred people a day. We also provided drinking water for the people in the stadium."

Dr. Schechtman showed photographs of many of his patients at the Doe Stadium IDP camp. Some survived, others did not. He described an eight year old girl who had come to his clinic with cholera:

"She had severe dehydration, was cold to the touch, pulseless, no blood pressure, couldn't sit up on her own, wouldn't open her eyes unless we caused her some painful stimulus, and her veins were so collapsed that we couldn't get a line into her. We put in a naso-gastric tube to give her oral rehydration and in the miracle of cholera patients, two days later she looked healthy and she was able to go home. It was victories like this that made some of the tragedies easier to bear and made it almost impossible to leave."

Fighting picked up again in a surge locally called "World War II" when the LURD rebels fought down into the city of Monrovia proper, capturing the port area called Foodport where all of the food was stored. In response, the Doctors Without Borders team in Doe Stadium pulled out and withdrew its international volunteers to the center of Monrovia. The local staff decided to stay at the stadium, continuing to treat patients despite the danger.

Converting a House into a Hospital

Once again the Doctors Without Border staff had been forced to evacuate to a safer location. Knowing that huge medical needs were going unfulfilled, the staff decided to improvise. They turned a nine-bedroom house they were renting into a fifty-bed hospital. "In the backyard we put up a fifty-thousand liter water bladder. In the corner we put up the cholera tent. And then in the old water tower we set up a morgue."

Their living room was converted into a pediatric ward with more than twenty patients, their mothers sleeping beside them on mats. In the downstairs hall the MSF team built an emergency ward.

"Malnutrition was a big problem. There was a child named Amos who only weighed about five-and-a-half pounds, and I was really surprised when I learned that he was eight months old. Five-and-a-half pounds is a small newborn, and an eight-month-old would normally weigh fifteen or twenty pounds. He was severely malnourished and he also had pneumonia. Despite our best efforts he died days later."

Dr. Schechtman told the audience that the majority of the fighting was of a shoot-and-run variety. Troops would fire their weapons into the air in order to scare off civilians, then loot their homes. Most of the injuries, Schechtman reported, were from falling shrapnel and stray bullets.

Schechtman described one of his patients, a two-year-old girl who had been shot through the face by a stray bullet as she slept with her mother. "Her mother didn't know what was wrong but noticed a spot of blood on her cheek. The mother rushed her to our hospital, where one of our student nurses noticed that just under her chin was a bullet lodged under the skin. The bullet had hit her cheek on one side, passed through, broken her jaw, and lodged under the skin. We were able to remove the bullet and treat her wounds. She made a good recovery."

Brief Peace Followed by More Fighting

When the fighting subsided, Doctors Without Borders was able to bring in some of the huge resources this international charity is able to command. "We landed two 747s with more than sixty tons of medical supplies within three days of requesting it. And we used those supplies for expanding our project into a big field next to our house. We set up an outpatient clinic, a waiting area, a dressing room, an obstetrics clinic, and a large tent for malnourished children."

During the break in the fighting, the MSF staff expanded the hospital they had built in their rented house, setting up a pharmacy in the garage, putting tape on the windows to decrease the likelihood of shattering when mortar shells came, and set up a bunker in the basement to hide from shelling.

"When there was a brief break in the fighting, we could load people into cars in a caravan and send them thirty minutes away to a war surgery hospital where they could be treated for severe injuries."

In August 2003 Charles Taylor finally agreed to go into exile in Nigeria. Peacekeepers from West Africa arrived in Liberia in order to stabilize the situation there. "When the fighting stopped, the medically ill seemed to swarm to the hospital and we realized that people with severe medical problems were just sheltering at home, hiding from the bombs and the flying bullets and essentially dying at home."

There were no blood reserves for giving patients transfusions. If a sick person needed a blood transfusion, they would have to bring a person, usually a family member or friend, to donate blood on their behalf. If a patient was unable to bring somebody with HIV-free blood who was also compatible with their blood type, the patient would likely die.

"The Liberians have been through so much tragedy over these thirteen years of fighting," Schechtman lamented, "chased from their homes and not able to support themselves."

Dr. Schechtman said that the situation in Monrovia is far from over. United Nations Peacekeepers are the largest force of its kind in the world, but they have yet to expand much beyond the capital of Monrovia. Most of the country continues to be held by rebel strongmen, the population is still being exploited, and access to even basic medical care remains a rare luxury.

More About Doctors Without Borders

DWOB was founded in 1971 as an international humanitarian aid organization. They do medical work in more than 80 countries around the world, currently running more than 400 projects. "Our mission statement is to work with populations in danger," Dr. Schechtman said. "We also work with neglected populations. For instance, they have projects with street children in Guatemala and the Philippines; populations which aren't necessarily in the most remote or war-torn areas, but populations which haven't been getting medical care or attention otherwise."

Doctors Without Borders puts more than 2,500 international medical volunteers in the field every year, and they have more than 13,000 local or national staff. Particularly unique about MSF, Schechtman said, is that they raise more than eighty percent of their funds from private donors rater than through governmental sources.

"The grandmother who gives ten dollars a month to the organization from her pocket book makes up the biggest portion of our revenue. Our annual budget now is more than $300 million. And the fact that we're not taking most of our money from government sources gives us incredible freedom to direct our interventions to the places and the populations that need it most, rather than being held restricted by political or governmental agendas that might say where, when, or what sort of work you can do."

Doctors Without Borders welcomes volunteers who are medical professionals but also other kinds of skilled professionals. "On the medical side, they take doctors, nurses, epidemiologists, and people with public health backgrounds," Schechtman said. "And on the nonmedical side they have administrators, people with financial backgrounds, and almost a catch-all category, their logisticians."

Schechtman explained that the logistician is responsible for water, sanitation, building wells, latrines, electricity supplies, making sure the international volunteers and the hospital structures are functioning, keeping the car fleet running, as well as maintaining supplies.

"They're sort of jacks-of-all-trades. I think their most important skill is management. So people of all varieties of backgrounds can be good logisticians." Doctors Without Borders requires a six- to twelve-month commitment for the first project. Sometimes after completing the first project people are able to go for shorter missions.

MSF covers all of their volunteers' expenses when they are working with the organization. This includes travel, room and board, medical insurance, and evacuation insurance. They also receive a modest stipend, about $650 a month, which goes up to about $900 a month after the first year.

Earlier Missions in Uganda and Guatemala

Andrew Schechtman received his BA from UC Berkeley in psychology and pre-med. He completed his MD at UCLA in 1993. Upon graduation, Dr. Schechtman did his family practice residency in Martinez, California, across the bay from San Francisco. "I knew I wanted to do some work in tropical medicine and after residency I went to New Orleans where I did a five month diploma course in tropical medicine, learning about tropical diseases."

Shortly after completing his tropical medicine training, Schechtman went on his first mission with Doctors Without Borders, in Uganda. There, Schechtman saw patients with African trypanosomiasis, or sleeping sickness, a fatal disease if left untreated, caused by a parasitic infection transmitted by the bite of a tsetse fly.

The second mission Schechtman worked on with Doctors Without Borders was in November 1998 in Guatemala, shortly after Hurricane Mitch.

 "In Guatemala, my project in the Eastern part of the country was to assess remote villages, which had been cut off from all communications since the hurricane. Roads were washed out and there were villages of 500, 1,000, 2,000 people sometimes up in the hills that hadn't been heard from since the hurricane. So our project involved flying in helicopters, landing in these remote villages, and then doing a blitzkrieg-style clinic where for two hours I would see anybody sick in the village who would come, often seeing 40 to 60 patients in two hours. And as part of doing this it allowed us to assess the medical status of the community and as I was doing this, a logistics person would be assessing the water supply and sanitation."

Stemming from his training in New Orleans Andrew Schechtman holds several positions with the Ochsner Clinic Foundation in New Orleans, including Acting Co-program Director of their Family Practice/Internal Medicine program and Acting Program Director of Ochsner's Family Practice Residence program.

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To find out more information about Doctors Without Borders' organization, current projects, and volunteering details, their website is www.doctorswithoutborders.org, or you can contact Lorna Chiu at the Los Angeles Office.
2525 Main St. Suite 110. Santa Monica, CA 90405. tel: (310) 399-0049.