Public health education for Liberian refugees.

During June of 1996, I served on a short-term mission team that worked with Liberian refugees living in the Cote d'Ivoire. I taught public health, while colleagues taught the Bible and general education principles. We understood that refugees are persons who must leave their homes in a hurry, most often under frightening conditions, carrying with them as much as they can. When visiting with the Liberian refugees, it became apparent that this description did not adequately convey the horror that this group experienced -- the loss of family and friends, the feelings of displacement, the despair-inducing poverty, and the health risks that they endured. Some Background Freed American slaves settled Liberia, a small country on the west coast of Africa, in the late 1800s (1). The people felt strong ties with the United States and even named the capital city Monrovia after the American President, James Monroe. Historically, Liberia has lacked adequate housing and sanitation (1) and has had high infant and childhood mortality rates (2,3). * In 1990, Liberia plunged into a brutal civil war (4) that continued for years. A result of the war was a sick, malnourished, and displaced population. Mortality rates were high, especially among children (5,6). By June 1996, an estimated 600,000 Liberian refugees had fled to the neighboring country, the Cote d'Ivoire (Ivory Coast). * Our missionary team targeted Liberian refugees living in the Toulepleu District of the Cote d'Ivoire, an inland area bordering Liberia. In two one-week courses, I worked with two groups of refugees, lay pastors and community health workers, teaching public health, disease prevention, and self-care. The Morning Class This class was primarily for male lay pastors who would receive 24 contact hours of seminary education on public health. Lutheran high school students also attended the class to complete a course on health. The 86 participants met in a church because no other facility had adequate space. They sat on benches with no back support, and all light and ventilation came from open doors and unscreened windows. Eleven of the participants were Ivorian pastors who did not speak English; thus, a missionary translated the lectures from English into French. In conducting the course, I used lay terms and gave many practical examples. The class decided that students could ask only three questions on any given topic before moving on to the next subject. At the first session, I presented graphics on a flannelgraph but abandoned this approach in favor of printing on a blackboard, which the participants preferred for taking notes. The participants also requested evaluations. Thus, three quizzes and a final examination were given. At first, communication proved difficult because in Liberian English, most ending consonants are dropped. This problem eased as the week went on, but impasses in communication did occur because of cultural differences or misunderstandings with language. Often participants helped move the class along by offering examples or analogies. For example, when some members failed to understand the word "lump," one participant pushed his tongue into his cheek to demonstrate what a lump looks like. Another assisted with the concept of child spacing by explaining that one does not plant stalks of corn too close together because they become spindly, and the same concept applies to children. Topics in this class included the agent-host-environment epidemiology model, the natural history-of-disease model, selected common diseases, principles for evaluating traditional medicine, indicators that a person needs to see a health professional, and maternal and child issues. I had planned to have a general discussion of maternal and child health issues for the last lecture but focused primarily on pregnancy because participants had such an interest in the topic and asked so many questions, abandoning their own three-question rule. …