Redemption

Today was my first site visit to one of six hospitals we are supporting in Liberia, along with over 45 clinics and 2 mobile medical teams.  I was a little apprehensive about the visit because I didn't know what I would find; what I would smell; what I would see.  By title I direct the health programs for my organization in Liberia, but the reality is that I have only been in the country 7 days.  I haven't had enough time to become sufficiently knowledgeable, connected and practiced to support our health teams fully.  Yet, daily the pressure for competency mounts and whatever my stage of development, my organization's Liberian health buck stops with me. 

It's the way I like it.  These are the sobering statistics we are tackling in Liberia.  1 in 100 women die at birth.  15 of 100 children don't make it to five years of age.  The average Liberian makes $1.28 a day.  Liberia sits near the bottom 10 poorest countries in terms of GDP and physical health indicators.  The civil war which began in 1989 left the country in shambles, transforming a former jewel of West Africa into a clog of blown up cement, cut off hands, gang rape victims and eviscerated hearts.  The election of Ellen Johnson Sirleaf, Africa's only female President, six years ago undoubtedly improved the situation.  One can walk around in the day without fear.  One can buy brie and refrigerated Kit-Kat’s in the Lebanese owned grocery stores for a price.  There's no McDonalds or KFC!   But the consequence of over a decade of war was grave depriving an entire generation of a formal education and forcing what was left of a professional class to flee. 

There are only 52 Liberian doctors serving 3.5 million people.  To put this into perspective, the residency program in which I trained in Oakland, California had 75 pediatricians alone.  There is not one Liberian orthopedist, not one heart surgeon, not one anesthesiologist in the country.  The Ministry of Health has boosted the number of doctors to around 200 by hiring expatriate doctors from Uganda, Tanzania, Congo, Kenya… but still the ratio is only 1 doctor per about 20,000 people and the hiring of expats (including myself) has disadvantages including a transient workforce, a cohort who themselves could be better trained and cultural competence issues.  I am not trying to overstate the importance of doctors because relative to the basic provision of food, clothing, shelter, education and jobs, it is not important.  But access to basic health care is a proxy of how a nation treats its people, accidents do happen, some pregnant mothers will require C-sections or they and their baby will die and in developing countries like Liberia, antibiotics, anti-parasitics, vaccines and IV fluids save lives.  Malaria is the number one killer here, exceeding that of HIV and TB combined.  In thirteen years of medical practice in the United States, I had never seen measles cases.  Today I saw three.

The particular hospital I visited today resembles a school because it once was one.  The hospital is the largest hospital run by the Ministry of Health and Social Work in Monrovia and is painted on the outside a cheerful turquoise blue with murals dispersed intermittently on the inside encouraging passer-bys to carry their babies correctly, immunize, or eat a balanced diet.  There is a palpable confidence in the open hallways, which are hot and sun streamed.  No one moaning.  Good flow.  Sanitation workers cleaning.  Like in the 19th century, I say the best predictor of hospital health in sub-Saharan African in the 21st century is the absence or presence of stench.  This hospital certainly has a smell but it is more the musty smell of hard work, bodies that have experienced too much and chronic sweat.  Heck there are toilets at the hospital whose tanks you admittedly have to fill yourself with water taken from large plastic cisterns in buckets, but hell there are toilets!   I can’t tell you how many hospitals I have been to without toilets.

The organizations with which I work supports specifically the pediatric service but pays for the fuel, oxygen, and generators of the entire hospital.  In pediatrics we have hired a foreign doctor to work and organize the service, a drug manager who controls and dispenses drugs which we pay for, and a logistician that makes sure that the pediatric teams are supplied with what they need.  The Ministry of Health pays the salaries for the hospital physician assistants (PA), nurses, and nursing assistants, but a big problem is that their salaries are $213, $188 and $75, respectively.  This leads to a cash strapped workforce that often arrives late because of transportation issues or decides not to come to work at all because they have to pick up 2-month-late-government-issued-checks downtown.  The Ministry does pay for three other doctors including the hospital director and medical director a higher salary of around $1000 a month.  It is with 4 doctors the whole hospital is run.  In general no hospital in Liberia has more than 4 doctors because of the country shortage.  The majority of medical care is provided by PA's and nurses.  With these challenges our organization's doctor and his team have still created a good 80 bed pediatric ward, an intensive care nursery and the city's largest malnutrition ward where it is indescribably fun to witness the skinniest children trying to get fat off of UNICEF fortified milk and Plumpy Nut.  It never happens!  Our doctor has also been able to maintain the spirit of the staff by modeling good work, providing frequent trainings and making the work environment nice by purchasing new beds, equipment and paint.  When I visited the pediatric wards, the care teams appeared almost happy.  The slim patients looked up at me wide eyed, thinking literally, what’s up? Babies breast freeding their mothers looked askance.  Toddlers reached if they desired to bat a goat.  This is sometimes what I think it feels like to have children.

We have much to do.  Our charts are a mess.  We have to negotiate with the Ministry an increase in salary of health workers to discourage corruption.  We need to increase the number of foreign doctors who can train Liberian health professionals well while increasing transparency of the system. We need to measure not just quantity of care but quality of care.  We need to learn to count results good or bad, better. But we are somewhere.  It’s a new role for me.  It’s hard not to want to just dive in at problems-- pull off the sweats--but my job now is to not be the doctor or even program manager, but to work with my country director to set the vision for our health program and enable those reporting to me so that their teams can reach not individual hundreds but collective tens of thousands.  It's all very daunting and exciting.  What's more, it just became week 2.