Friday, February 27, 2009
Disappearing Doctors
Gia and I have been working at Martha Tubman Memorial Hospital (MTMH) for almost two full weeks now. MTMH is a seventy-bed government-run hospital for southeastern Liberia. Before we arrived, there were only two physicians, including the hospital administrator who is an ophthalmologist and a surgeon who is funded by an NGO named Merlin. As the hospital administrator has many competing duties, the Ethiopian surgeon, Dr. Tekle, essentially became the only physician making rounds on patients. Before we arrived, Dr. Tekle rounded three times a week on the inpatient wards, including all female, male, obstetric, pediatric and surgical patients. Twice a week, he is in the operating theatre performing elective surgeries. He is the on-call physician 24 hours a day, 7 days a week, staffing the entire hospital, including the emergency department. Since Gia and I have arrived, Dr. Tekle jokes that he has finally some time for rest and relaxation.
Our first morning at MTMH, we joined him on his rounds and were left astounded and overwhelmed at how this one physician could be a pediatrician, general internist, obstetrician, and surgeon. Many African countries are suffering from “brain drain,” a term given to the luring away of African doctors to practice in Westernized nations like the United States. Liberia suffers from this, but its “brain drain” is also compounded by the small numbers of students pursuing medicine as a career. Approximately twenty Liberian doctors graduate each year from one medical school that is currently not officially accredited. So it is not surprising that here in Zwedru at MTMH, there is only one physician practicing who is not a native Liberian. While no country’s healthcare system is perfect, Liberia’s continues to lag behind not only in material resources, but more importantly, human capital. Without a steady supply of trained Liberian physicians, the Liberian healthcare system will continue to depend on expatriates, who also have rapid turnover and burnout from the overwhelming healthcare needs and devastation of infectious diseases, including HIV/AIDS, tuberculosis, and malaria. Human capital is vital, and currently, Liberia is lacking that resource post-civil war.
The $1,000,000 question then is this: What can we do?
Our first morning at MTMH, we joined him on his rounds and were left astounded and overwhelmed at how this one physician could be a pediatrician, general internist, obstetrician, and surgeon. Many African countries are suffering from “brain drain,” a term given to the luring away of African doctors to practice in Westernized nations like the United States. Liberia suffers from this, but its “brain drain” is also compounded by the small numbers of students pursuing medicine as a career. Approximately twenty Liberian doctors graduate each year from one medical school that is currently not officially accredited. So it is not surprising that here in Zwedru at MTMH, there is only one physician practicing who is not a native Liberian. While no country’s healthcare system is perfect, Liberia’s continues to lag behind not only in material resources, but more importantly, human capital. Without a steady supply of trained Liberian physicians, the Liberian healthcare system will continue to depend on expatriates, who also have rapid turnover and burnout from the overwhelming healthcare needs and devastation of infectious diseases, including HIV/AIDS, tuberculosis, and malaria. Human capital is vital, and currently, Liberia is lacking that resource post-civil war.
The $1,000,000 question then is this: What can we do?
Wednesday, February 25, 2009
Medical Records
While working with Tiyatien Health, Gia and I will be trying to evaluate our medical record keeping system and improve it. Our HIV Equity Initiative Clinic has over 200 patients enrolled now after only 2 years in existence. With a growing cohort of patients, it is imperative that Tiyatien Health have accurate medical records so that we can continue to treat our patients with the highest of standards. So far, Gia and I have examined almost all of the HEI Clinic's charts. As infrastructure in Liberia is still behind, paper charts continue to be used in the Clinic as well as at Martha Tubman Memorial Hospital, where the Clinic is based. Our goal while we are here is to help roll-out an electronic record system and train essential staff on using it. We hope that in doing so, medical records will be accurate, up-to-date, and easily accessed for further research opportunities.
Saturday, February 21, 2009
Friends
A cornerstone of Tiyatien Health’s comprehensive community-based HIV/AIDS care is accompaniers. Accompaniers are community members who provide support to their assigned persons living with HIV / AIDS (or known as "PLWHA" or "friends").
This week, Gia and I were able to follow an Accompanier Leader, Agatha, while she visited with some of the accompaniers and their friends. As the sun set in Zwedru, we walked 45 minutes to Kudah Bye Pass, a neighborhood of Zwedru. We met two accompaniers who both said that they decided to become an accompanier to help those that are less fortunate than them. Every day, they walk short and long distances to visit their friends, provide their friends with emotional support, and to perform directly observed therapy for anti-retrovirals (ARVs). In a resource poor setting like Zwedru, it is amazing how strong the community is and how members seek to take care of each other. In the United States with 24 hour electricity, clean, running water, flushing toilets, and reliable transportation, the sense of community becomes lost as neighbors tend to become secluded in their own apartments, houses, and condos. So it is touching and amazing to see how the accompaniers here have volunteered to take care of those that would be so stigmatized due to their HIV/AIDS status.
It can also be heartbreaking when a friend decides to stop taking their ARVs as one of our friends did this week. Agatha and the accompanier sat and talked with the 16 year old girl to let her know the importance of taking these medications were -- not only to her, but to her 9 month old baby son. The friend still wouldn't take the medications as she said she was healthy and fine, but her accompanier convinced her to come to the HIV Equity Initiative (HEI) Clinic the next day for further follow-up. She did arrive the next day with her accompanier, and we again went over the importance of taking ARVs and adherence. She left with her little son, agreeing to restart her medications.
I question whether she will start her medications as she promised. Without an accompanier, I'm certain that she would be lost; however, since she has a dedicated, devoted accompanier, I'm certain that he will continue to talk with her, educate her, and work with her.
This week, Gia and I were able to follow an Accompanier Leader, Agatha, while she visited with some of the accompaniers and their friends. As the sun set in Zwedru, we walked 45 minutes to Kudah Bye Pass, a neighborhood of Zwedru. We met two accompaniers who both said that they decided to become an accompanier to help those that are less fortunate than them. Every day, they walk short and long distances to visit their friends, provide their friends with emotional support, and to perform directly observed therapy for anti-retrovirals (ARVs). In a resource poor setting like Zwedru, it is amazing how strong the community is and how members seek to take care of each other. In the United States with 24 hour electricity, clean, running water, flushing toilets, and reliable transportation, the sense of community becomes lost as neighbors tend to become secluded in their own apartments, houses, and condos. So it is touching and amazing to see how the accompaniers here have volunteered to take care of those that would be so stigmatized due to their HIV/AIDS status.
It can also be heartbreaking when a friend decides to stop taking their ARVs as one of our friends did this week. Agatha and the accompanier sat and talked with the 16 year old girl to let her know the importance of taking these medications were -- not only to her, but to her 9 month old baby son. The friend still wouldn't take the medications as she said she was healthy and fine, but her accompanier convinced her to come to the HIV Equity Initiative (HEI) Clinic the next day for further follow-up. She did arrive the next day with her accompanier, and we again went over the importance of taking ARVs and adherence. She left with her little son, agreeing to restart her medications.
I question whether she will start her medications as she promised. Without an accompanier, I'm certain that she would be lost; however, since she has a dedicated, devoted accompanier, I'm certain that he will continue to talk with her, educate her, and work with her.
Wednesday, February 18, 2009
“Where are the American Doctors?”
Gia and I had just finished rounding on the male inpatient ward on our first clinical day at Martha Tubman Memorial Hospital (MTMH), a 70-bed government hospital that houses male, female, and pediatric inpatient wards; one operating theatre; an emergency room; and an outpatient department with 4 consultation rooms in Zwedru. As we were about to start rounds on the pediatrics ward, a physician assistant hurried down the hall and asked, “Where are the American Doctors?”
We were quickly taken to the Emergency Room, which consists of a small 10 x 10 room with two stretchers and a sheet to compartmentalize the room. On a stretcher, a 46 year old male lay, breathing fast and deep and unresponsive to pain or sternal rub. The wife explained in Liberian English that her husband had fallen from a tall tree and hit his head 24 hours ago. He was referred from his community health center to MTMH for evaluation and management.
In the United States, this man would have been quickly evaluated by ED physicians and trauma surgeons. He would have already been in a cervical collar, hooked up to vital sign monitoring, and an endless array of X-rays and a head CT would have been performed within an hour – if not minutes – after he arrived for medical evaluation. In Liberia, Gia and I, two resident physicians in Internal Medicine, were now asked to become the ED physician and the trauma surgeon. We used purely physical diagnosis skills to note that he had left sided hyperreflexia, a clavicle fracture, and bilateral pneumothoraces. He also likely had a brain hemorrhage although no CT can be obtained. We consulted the general surgeon at MTMH, who came quickly, to assist in the evaluation.
This sad case illustrates what I know Gia and I will continue to struggle with while we are seeing patients here in Liberia, and that is the lack of resources and infrastructure to be able to care for patients the best we possibly can. Knowing that this same patient, if he had presented to a US Hospital, would most likely be in the trauma ICU with continuous vital sign monitoring, one nurse caring for him 24 hours a day, radiology and laboratory capabilities, and trauma surgery expertise, but is instead in the medical male ward in Liberia with no continuous monitoring, one nurse who is caring for not only him but 10 other patients, and no radiology and limited labs, is frustrating and unjust. It is these feelings that I believe will continue to make both of us pause, reflect, and consider how we can make this wide divide in health care narrower.
We were quickly taken to the Emergency Room, which consists of a small 10 x 10 room with two stretchers and a sheet to compartmentalize the room. On a stretcher, a 46 year old male lay, breathing fast and deep and unresponsive to pain or sternal rub. The wife explained in Liberian English that her husband had fallen from a tall tree and hit his head 24 hours ago. He was referred from his community health center to MTMH for evaluation and management.
In the United States, this man would have been quickly evaluated by ED physicians and trauma surgeons. He would have already been in a cervical collar, hooked up to vital sign monitoring, and an endless array of X-rays and a head CT would have been performed within an hour – if not minutes – after he arrived for medical evaluation. In Liberia, Gia and I, two resident physicians in Internal Medicine, were now asked to become the ED physician and the trauma surgeon. We used purely physical diagnosis skills to note that he had left sided hyperreflexia, a clavicle fracture, and bilateral pneumothoraces. He also likely had a brain hemorrhage although no CT can be obtained. We consulted the general surgeon at MTMH, who came quickly, to assist in the evaluation.
This sad case illustrates what I know Gia and I will continue to struggle with while we are seeing patients here in Liberia, and that is the lack of resources and infrastructure to be able to care for patients the best we possibly can. Knowing that this same patient, if he had presented to a US Hospital, would most likely be in the trauma ICU with continuous vital sign monitoring, one nurse caring for him 24 hours a day, radiology and laboratory capabilities, and trauma surgery expertise, but is instead in the medical male ward in Liberia with no continuous monitoring, one nurse who is caring for not only him but 10 other patients, and no radiology and limited labs, is frustrating and unjust. It is these feelings that I believe will continue to make both of us pause, reflect, and consider how we can make this wide divide in health care narrower.
Friday, February 13, 2009
Everything's Fah-Fah
We arrived in Zwedru, located in the southeastern corner of Liberia on Wednesday, February 11. After a ride through Liberia’s country side, we were greeted warmly by Tiyatien’s staff members, including Project Coordinator Weafus Quitoe and Technical Advisor Bernard Togba. First impressions last, and our first impression of Liberians are of warmth, openness, friendliness, and charisma. We were treated to a meal of cassava leaves with game (i.e. venison) and rice. After our stomachs were full, our hosts took us on a tour of Zwedru, including the center of town, or the “triangle,” which boasts street side shops, cell phone charger booths, and bars. We arrived on Armed Forces Day, a national holiday, so the night was not as lively as it would be on any other night, but still, the streets were buzzing with activity.
Gia and I are staying at the Tiyatien Guest House, located across the road from Tiyatien Health's Office and only a short five minute walk from Marth Tubman Memorial Hospital. While accommodations are sparse, they are comfortable. We are thankful to be surrounded by such good company in our Liberian hosts, who have made us feel at home and free (as they like to say here in Zwedru). We are both fah-fah (translation from Liberian English - We are both cool and everything's okay).
The Blog is Live Again
The Tiyatien Health blog is alive again. For the next two months of February and March 2009, it will chronicle two medical volunteers’ work in Zwedru with Tiyatien Health. Gia Leddy is a third year internal medicine – primary care resident, and Lindsay Kim is a second year internal medicine – primary care resident. Both are based out of Boston’s Beth Israel Deaconess Medical Center. Both Gia and Lindsay are committed to Tiyatien Health’s mission to provide compassionate, quality healthcare to the rural poor and improving justice through healthcare for all.
Subscribe to:
Posts (Atom)