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Introduction

Liberia is a diverse country, and one that has undergone rapid socio-cultural change even in the last 25 years. This makes generalizations about "Liberian people" and "Liberian culture" somewhat difficult and overly simplistic. A Liberian from the capital city, for example, may feel much closer to American culture than to that of someone from the rural hinterland. All Liberians have, however, been touched in some way by the incredibly bloody conflict that was the Liberian civil war. The following is written in an attempt to share some of the common experiences Liberians suffered during their war and elucidate some of the social and cultural responses to it.

Liberia is located on the "grain coast" of West Africa, between 6 and 9 degrees north of the equator, bordering Sierra Leone, Ivory Coast, and Guinea. It has vast resources of iron ore, timber, diamonds, and gold, but due to both the conflict and widespread corruption, most Liberians have never benefited from these. There are approximately 16 different ethnic groups indigenous to the country, including Kpelle, Bassa, Gio, Kru, Grebo, Mano, Krahn, Gola, Gbandi, Loma, Kissi, Vai, and Bella. "Americo-Liberians" (those descended from former slaves) compose about 5% of the population. Infant mortality rates in the country are high, estimated at 108.1 deaths / 1,000 live births. Life expectancy at birth is 56 years for men; 61 years for women. The average woman bears 6.23 children in her lifetime. Literacy rate for those older than 15 years is 53.9% for men, but only 22.4% for women (CIA World Factbook 1996). World Health Organization (WHO) data shows that in recent years the health status of Liberians has declined: Disability adjusted life expectancy (DALE) measures the "expected number of years to be lived in what might be termed the equivalent of 'full health'" (WHO, 2000). According to the WHO, Liberians have a DALE of 34 years, ranking 181st among 191 nations.

A Brief History of the Conflict in Liberia

The Liberian conflict has early historical roots when freed American slaves resettled on the coast of West Africa in the 1820's. The settlers generally regarded themselves as superior to the "tribal" peoples of the interior, and over time established civil controls to bring rural areas increasingly under centralized control, located in the coastal capital Monrovia. The national army became the main tool to enforce this control. By the 1970's, Liberian presidents came under increasing political pressure to reform, yet the entrenched political patronage system that had developed, coupled with a depressed worldwide economy, made reforms ineffective.

In 1980, an uneducated junior officer in the army, Samuel Doe, led a coup with the support of his own Krahn ethnic base. Instead of instituting wide-ranging reforms, however, Doe began using the state solely as a means of personal enrichment. The Doe years are remembered by most Liberians as being particularly repressive - not merely brutal, but "marauding six years of rape and plunder by armed marauders whose ideology is to search for cash and whose ambition it is to retain power and accumulate and protect wealth" (Sawyer, 1995, p. 176). To maintain a personal grip on power, Doe armed the Krahn and Mandingo ethnic groups under the guise of the Armed Forces of Liberia (AFL) to spread terror into the countryside.

In 1989, Charles Taylor, an American-educated Liberian economist trained in guerrilla warfare in Libya and head of the National Patriotic Front of Liberia (NPFL), crossed into Liberia, and began to attack government troops. The Doe government had become so hated that the Gio and Mano peoples of the county reacted very positively to Taylor, and violence began to spread out of control. Armed bands claiming allegiance to the NPFL began to engage in ethnic violence against anyone suspected of being Krahn or Mandingo. Doe was eventually caught by a splinter NPFL group, and graphically mutilated on videotape, the sale of which spread all over West Africa.

In 1990, the Nigerian-led peace keeping force ECOMOG landed in Monrovia in an attempt to hold the capital as a "safe one." A third faction was formed in 1991 by Liberians who had taken refuge in neighboring Sierra Leone, and became known as the United Liberation Movement for Democracy (ULIMO). So many civilians were armed (the UN estimates 60,000) that the leaders were unable to completely control their own elements. None of the militias could pay their forces regularly, so the fighters had to subsist on what resources they could procure by gun. The simultaneous break-up of the Soviet Union ensured a cheap and steady supply of automatic weapons (Kalashnikov rifles or AK-47s could once be bought in Liberia for between $9-$18 US). Most fighters were young, and settled in the resource-rich areas of the country, especially diamond-producing areas, agricultural areas, or places where humanitarian-aid convoys could be looted. They commonly used forced-labor to work for them, in agriculture, mining, cooking, or transporting and selling looted goods.

In 1993, 600 displaced people, mostly women and children, were massacred at the "Harbel" displaced-persons camp on the Firestone Rubber Plantation. This increased domestic and international pressure for a series of signed cease-fires, which, though never really effective, eventually did allow for country-wide elections in July 1997. As he had controlled most of the countryside of Liberia for much of the previous eight years, Charles Taylor easily won these, to become the newest Liberian President.

In eight years of conflict, over 150,000 people died, or one out of every 17 Liberians. Many of Liberia's once 2.5 million people were forced to flee from their homes, giving Liberia the largest percentage of refugees and internally displaced people in the world. Although efforts have been made to disarm the warring factions, many feel that renewed fighting will remain a possibility for quite some time. Liberians initially were optimistic about Charles Taylor's promised reforms ("I will not be a wicked president"), but the situation continues to deteriorate. In the capital city of Monrovia, for example there is no running water, no sewers, and no electricity. There is no independent media and "the brutal security forces provide the one lasting reminder that a government does exist" (Onishi, 2000, p. A18). Taylor, his family, and friends are systematically looting and destroying Liberia and there is little prospect for change (Onishi, 2000).

Violence Against Women During the War

As is often the case in refugee-producing situations, women have been especially affected by war-related violence. Many were forced into sex during the conflict in order to feed themselves or their family, to get shelter or clothing, or for protection and safety. In one survey documented by the American Medical Association, 49% report experiencing one act of physical or sexual violence from a soldier or fighter during the war; 32% report they had been strip-searched; 17% report being locked-up, tied, or beaten; 15% report they had been raped; and 42% say they had witnessed a soldier kill or rape someone else (Swiss et al, 1998).

Extreme sensitivity should be taken in asking female patients about sex. Especially older Liberian women may even feel it inappropriate to be questioned about sex by a younger person. In addition, issues of "rape" carry considerable social stigma. The word itself may not be an exactly-translatable term into Liberian-English, hence one should use more general terms like "forced sex." Sensitive questioning should be prefaced by deferential remarks, such as "Excuse me, Ma, but . . ."

Communication and Health Care

Even though English is the "official" language of Liberia, important semantic differences exist between "Liberian English" and "American English" that necessitate extreme care in communication. For instance, seemingly simple and straightforward questions like "what has your child eaten today?" may often elicit a false negative answer. In this case it is necessary to understand the cultural context of "eating" in Liberia, in which the word "food" is often taken to mean "rice." Rice is THE staple food in Liberia, and "to eat" literally translates into Liberian English as "to eat rice." One researcher quotes a Gbande man: "A Gbande may eat bread, potatoes, cassava, plantain, or yams, and still consider himself virtually starved for lack of food if he has not had his bowl of rice" (Jarosz 1990).

It is recommended that, in case of any doubt, an interviewer use the most general term possible (Jarosz, for instance, in a nutritional survey, had to alter her wording to "Tell me everything you gave the baby from the time the baby woke up yesterday morning until the time the baby woke up today" (Jarosz, 1990).

Health Concerns and Beliefs

Infectious Diseases

Liberians in the U.S. or Europe are no more likely to suffer from endemic West African diseases than anyone else, although there is a high incidence of the sickle-cell gene. Liberians just arriving or visiting from West Africa, however, may suffer from a variety of tropical ailments, including latent schistosomiasis, chloroquine-resistant malaria, yellow fever, cholera, typhoid fever, hepatitis A or B, or STD's (especially gonorrhea, syphilis, Pelvic Inflammatory Disease/PID, or chancroid).

Nutrition and Body Weight

Especially Liberians from rural areas may have different body-imagery than the "ideal" lean Western type. A "healthy" body in Liberia is perceived as a stout one, and is also associated with wealth and prosperity; the stereotypical Liberian "big man" politician would probably be seen as obese and at-risk for heart disease by a Western nutritionist. The palm oil that Liberians prefer to cook their food with is high in saturated fats, but also high in vitamins.

Traditional Medicines

The use of indigenous medicines in Liberia is extremely common, and most individuals have some knowledge of certain plants that may be self-applied in times of sickness. Liberians also have an assortment of indigenous healers, or "native doctors," including herbalists, Muslim holy men, bone specialists, and increasingly, faith healers. The treatments are often complex rituals. For example, in bone-setting a patient's fracture, the leg of a live chicken is broken at same time. The practitioner then treats both fractures: oil is rubbed over the site, and small twigs are then wrapped around the wound, which has been covered in a chalky poultice. At the time that the chicken leg is healed, the patient is believed to be healed too, and the poultice removed.

Most Liberians see no discrepancy in attributing the etiology of disease to both naturalistic (biological) and supernatural causes. The question of immediate "cause" may be commonsensical or biological, but the "why did this occur to me" may be attributable to sorcery, taboo violation, or some form of contagion (especially from breeze, cold, water, or dreaming). Consequently, Liberian refugees may commonly combine indigenous and biomedical forms of treatment simultaneously. If a physician suspects indigenous medication may be interfering with his/her own prescribed treatment, the person in charge of decision-making for the sick person (perhaps a family head) may be sensitively asked what other forms of treatment are being concurrently given. Stay away from making value-judgments about the efficacy of the other treatment, as this may simply result in false information being given.

Sexually Transmitted Diseases

It would not be at all unexpected for recent Liberian refugees to suffer from STDs, as poverty and lack of economic opportunity can cause sexual diseases to be quite rampant in camps (see Henry 1998). In Liberia, STDs are most often treated by oneself or by non-Western or "traditional" healers, typically herbalists or Muslim holy men, who may enjoy wide respect for their abilities. The medications are most often ointments or teas, though less commonly an enema or vaginal implant may be used.

Condoms are not widely used among Liberians, for reasons of in-country accessibility and/ or widely held popular beliefs, such as that the condom may "slip off" during use and cause internal complications. Even in refugee camps with access to some degree of health services, condoms are often not practically available, or may be sold at a cost preclusive for the average "cash-poor" refugee to afford.

Female Issues

Female "circumcision" or "female genital mutilation" (FGM) is quite common in Liberia, and is practiced by an estimated 95% of all Liberian women (also see editor’s note below). Obviously this is a sensitive topic, and one replete with highly charged emotional arguments from all sides "for" and "against." Westerners, and increasingly urbanized African women, decry the health effects of the operation, and the "humiliation" and "degradation" they interpret these women as suffering. Liberian women, however, typically view attempts to ban the practice as a direct assault on women and the highly secretive women's Sande society. This society is the only indigenous organization where Liberian women exert power in their own right without male interference. It is quite possible that a physician may be asked discreetly by a Liberian woman to perform this for her girl child. For a physician to personally decide how to respond to such requests, it becomes necessary, then, to understand the cultural context in which such a procedure takes place. In Liberia, a circumcised woman is considered a part of the women's society, a "clean" and "proper" adult eligible for marriage, capable of child-bearing, and eventually able to hold important societal offices.

FGM is performed in Liberia by the older "Zoes", the respected elders of the women's society. A Zoe usually also functions as a midwife, and typically commands considerable influence and respect in the community she serves. There are two main types of female circumcision practiced in Liberia: 1) Excision where the clitoris, and the labia minora are removed leaving the labia majora intact, and 2) Clitoridectomy only the clitoris is removed, leaving the labia majora and minora intact. FGM may be performed on a girl as early as age 3, but more often when they are immediately pre-pubescent. (Note: several states in the U.S. and other Western countries have passed legislation outlawing the practice of FGM.)

Editor's note: The above is written from the perspective of the article’s authors. Out of respect to the authors, no editing was done on that section. Out of respect to women, I want to note (as the authors noted), that there is an increasing recognition in both Western and African quarters that female genital cutting (FGC) is in no way beneficial to women. It is unlikely that all Liberian women view measures to prohibit the procedure as "an assault on women." The procedure is painful and there are health risks from infection as well as long-term problems. The bottom-line purpose of the procedure is to deny women sexual pleasure and thus enforce fidelity. As of January 18, 1999, female genital cutting is banned in Burkina Faso, Central African Republic, Djibouti, Ghana, Guinea, Togo, Egypt, and most recently, in Senegal. The executive director of UNICEF said, "Senegal's action is of great significance because it reflects the resolve of African women to end a cruel and unacceptable practice which violates the rights of girls to free, safe, and healthy lives" (New York Times, 1/18/99, p. A7). Web sites concerned with the issue include http://www.fgm.org/ and http://rainbo.org. For a more extensive discussion and current classification of FGC, readers are also referred to the section on Refugee Women in this site. C. Kemp

Common Medical Problems

Problems seen most commonly in newly arriving refugees from Liberia and other African countries (Ackerman, 1997; Gavagan & Brodyaga, 1998) are listed below. Please see the Infectious Diseases section for updates and further discussion of the below.

Recommended laboratory and other tests include:

Peripheral smear for malaria should be considered. Other problems that practitioners should be especially alert to are cervical cancer, ectoparasites, and post-traumatic stress disorder.

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Authors: Doug Henry and Lance A. Rasbridge

Edited by Charles Kemp

References

Ackerman, L. K. (1997). Health problems of refugees. Journal of the American Board of Family Practice, 10(5), 337-348.

CIA Online World Factbook, 1996.

Ellis, S. (1995). Liberia: A Study of Ethnic and Spiritual Violence. African Affairs, 94: 165-167.

Gavagan, T. & Brodyaga, L. (1998). Medical Care for immigrants and refugees. American Family Physician, 57(5), 1061-1068.

Green, E. (1992). The Anthropology of Sexually Transmitted Disease in Liberia. Social Science and Medicine, 35 (12): 1457-1468.

Henry, D. (1998). Health, Income, and Empowerment Among Sierra Leonean Refugees in Guinea. Technical report submitted to the United Nations field office, Gueckedou, Guinea.

Jarosz, L. (1990). Intercultural Communication in Assessing Dietary Habits: Liberia as an Example. Journal of the American Dietetic Association, 90 (8): 1094-1099.

Onishi, N. (12/7/2000). In ruined Liberia, its despoiler sits pretty. New York Times. Vol. CL, No 51,595, pp. A1, A18.

Swiss, S. et al. (1998). Violence Against Women During the Liberian Civil Conflict. Journal of the American Medical Association, 279 (80): 625-629.

World Health Organization (2000). Healthy life expectancy rankings. Accessed on the World Wide Web on October 14, 2000 at http://www-nt.who.int/whosis/statistics/dale/dale.cfm?path=statistics,dale&language=english