HIV Awareness Programme

Today, Tiyatien Health and UNHCR co-sponsored an HIV Awareness Programme in Zwedru. The day long programme started with a march to City Hall with the community. At City Hall, educational skits were presented. A cultural dance show was performed. Key HIV/AIDS leaders spoke, and a photo exhibit was shown. This afternoon, two local high schools will battle in a football (i.e. soccer) match. Below are some photos by Gia:

Tiyatien Staff Preparing for the Day

Cultural Dance Show

HIV/AIDS Photo Exhibit

A Captive Audience

Educational Skits

Performing a Needs Assessment in Fish Town

On March 17-18, Weafus, Tiyatien Health’s Project Coordinator, and I traveled 80 km from Zwedru to Fish Town, the capital of River Gee County. River Gee shares the southern border of Grand Gedeh County. Tiyatien Health visited Fish Town in November 2008 to perform an initial needs assessment for possible expansion of our HIV/AIDS services to this area. This was our follow up visit to determine whether any improvements had been made to the health care system and to further define the role Tiyatien Health could play in this community. Our visit was facilitated in large part by the UN Military (UN MIL), who play a significant role in most towns and communities in Liberia post-civil war.

Weafus and I visited the Fish Town Health Center and the still unfinished Fish Town Hospital. The Hospital continues to stand without proper completion of construction. It was to hold about 30-40 beds, an operating theatre, a pharmacy, laboratory, and stock rooms. Currently, the rooms are largely empty except for a delivery room and 1 room for antenatal care. Otherwise, since the Hospital is not operating, the inpatient wards have been moved into the Fish Town Health Center.

The Health Center holds 6 inpatient beds: 3 female, 1 male, and 3 pediatric beds. The Health Center sees approximately 700-1,000 patients a month with a staff of 1 Nigerian physician (who is the only physician serving in all of River Gee County), 1 Physician Assistant, 2 certified nurse midwives, 3 registered nurses, 1 lab technician, and 1 lab assistant.

As Tiyatien is considering expanding its services to all of southeastern Liberia, we found that Fish Town is completely lacking HIV/AIDS services. While HIV testing and counseling are performed, the clinic has no access to anti-retrovirals and cannot provide any treatment for patients with new diagnosis. Because of this, community members do not see a reason to get tested for HIV/AIDS as there is no further step after diagnosis for them. Instead, if a patient is diagnosed, they are referred to Martha Tubman Memorial Hospital, which is a 3 hour drive from Fish Town. Unfortunately, most patients are then lost to follow-up. Alarmingly, last year, Fish Town Health Center had 28 new diagnoses of HIV in pregnant patients. If you perform the math, this means that 28 women have HIV, 28 infants and at least 28 male partners have been exposed to HIV. This totals 84 people who are likely affected by HIV/AIDS in 1 year and are lost to treatment and care! It is a shame that anti-retrovirals exist, but so many patients do not have access to these live-saving medications due to poor infrastructure and poor health care systems.

Weafus and I also visited with all of the non-governmental organizations doing work in Fish Town, including German Agro Action, Medical Mondiale, and Dakonie/Community Union for Sustainable Development. Our aim was to share our mission with these local NGOs as well as to identify possible areas of partnership with them. For example, Dakonie/CUSD has a public health program that trains community members to educate others on basic hygiene practices and treatment of diarrhea in the villages. Tiyatien has a similar program in our accompaniers who are focused on HIV/AIDS treatment. If Tiyatien is to work in Fish Town, it seems that a collaboration between Dakonie/CUSD’s community health workers and our accompaniers would be fruitful in that both can train the other on their areas of expertise to provide a more effective and educated community health worker and accompanier.

Weafus and I will be writing a report on our visit and will make recommendations for Tiyatien’s possible foray into River Gee County. Overall, our visit to Fish Town was very productive, and it left us with the intense feeling that Fish Town could very much benefit from an HIV/AIDS organization like Tiyatien.

Fish Town Hospital

Fish Town Health Center

Medical Records at Fish Town Health Center

Inpatient and Outpatient Pharmacy

Pediatrics Ward (3 beds)

Celebratory Palm "Wine"

Today, Gia and I went to the hospital to say goodbye to our wonderful nurses, nurse aides, and staff that have been so gracious to us. Our male ward nurse, Sangai, arranged for a bottle of palm wine to be delivered to the hospital via a local palm wine “chief.” Palm wine is tapped from the tree, and it is only found in the villages and not in Monrovia. We couldn't figure out if there is any alcohol content since they call it "wine," but it tastes slightly sour and fizzy. Liberians tell us that Palm Wine makes you strong. Gia and I were so excited that we were able to share our first taste of this special drink with Sangai and our nursing staff.

Palm Wine

Nurse Aide, Lindsay & Sangai

Sangai drinking Palm Wine

Nurse Aide, Sangai, and Gia

New Midwifery School in Zwedru

Gia and I visited the new MacBain-sponsored/Merlin Midwifery School today.

The school has enrolled its first class that consists of 45 students, including 8 males (only the second time that they have allowed males into midwifery school!), with a range of ages from 18 to 43 years. Students are recruited through an extensive process, including submission of high school diploma, transcript, taking an entrance exam, and completing an interview. Once accepted, they do not pay for tuition or fees, and they are provided a dormitory and monthly stipend for food and incidentals (80 USD per month).

The program is 2 years. The students are in class from 8 AM to 4 PM Monday through Friday. During their first semester, they study anatomy, physiology, introduction to nursing, psychology, English, and math. During their second semester, they study pharmacology and start doing practical experiences at the hospital. They then get placed at local hospitals or clinics for practicum. After they graduate, they are required to stay in the Southeastern Liberia region for 3 years in return for their education. Their expected salary upon graduation is about $80 USD/month, but hopefully, this may increase to $110 USD/month. This system is very similar to the National Health Service Corps in the US.

The midwifery school shares facilities with a local high school located in Kudah Bye Pass, while they await construction of their own school on Monrovia Highway next year. They have a well-stocked library with nursing and medical texts. They also have a skills lab with models of the women reproductive system as well as a model arm to practice blood draws on. There are two main instructors who both hold bachelor's degrees in nursing.

Overall, this program will hopefully encourage midwives to stay in southeastern Liberia where there are so few trained midwives It would be awesome if this could be replicated with Physician Assistants, RNs, and Physicians in SE Liberia to improve the medical education system and the retention of medical personnel.

Model Venipuncture Arm

Female Reproductive System Models

Midwifery Students

Curriculum

Thank You to Our Liberia Staff

Gia and I are in the midst of preparing for our impending departure from Zwedru. We have been so thankful to work with our dedicated, passionate Liberia Team, and we expressed our appreciation with a celebratory dinner at the UN Logistics Base. Here are some photos from that night:

Amos and Alphonso

Neewray

Gia Feels "Off"

What does she have? First one to answer wins 100% Deet Spray.

Translating Office Visits to Data Collection

The HIV Equity Initiative (HEI) Clinic has enrolled almost 300 patients since 2007. With each visit, a plethora of information is collected, including weight, WHO Clinical Status, medication information, adherence, and more. Currently, the clinic used paper charts, and this has been working remarkably well given the infrastructure limitations. However, Tiyatien Health is moving towards an electronic database that will collect this information so that statistical information and data can be at our fingertips.

While Gia and I have been here in Zwedru, our colleague, Dr. David Kraemer at Kansas Wesleyan University has been working countless hours to make and refine a database for our HEI Clinic. With this database, each clinic visit will be recorded, accurate (no more messy handwriting!), and stored on a computer for easy access and retrieval. The database will also make it easy to provide summary statistics to our partners, including the Ministry of Health and the Liberian National AIDS Control Program, as well as help identify gaps and strengths in our program. It will allow us to perform research for dissemination and show the international community the success a local NGO like Tiyatien Health can do in a short time.

Gia, Dr. Kraemer and I have been in close contact during the last few weeks, spending hours on Skype and exchanging many emails, about making this database user-friendly, applicable to our clinic, and sustainable. We hope to recruit research assistants this summer to help us implement the database so that our Liberian Team has this powerful tool to help further our ability to care for our patients in the best way possible. Tiyatien is growing leaps and bounds, and we are excited to be a part of this very important process.

More Scenes from Zwedru

Boys Selling Goods

The Zwedru Open-Air Market

Neighborhood Children and Lindsay

Lindsay, Jackson (Save the Children), and Gia at President Doe's House

Jackson, Gia, and Julius (UNHCR) at President Doe's House

Scenes from Zwedru

A Typical Gas Station

Pet Monkey

The Woman Behind Zwedru's Dunkin' Donuts

Dunkin' Donuts - Zwedru Style - Hot and Fresh!

Cooking Eggs and Bread on a Hot Sunday

HIV Equity Initiative Clinic

Every Tuesday and Thursday at Martha Tubman Memorial Hospital, Consultation Room #2 in the Outpatient Department becomes the HIV Equity Initiative (HEI) Clinic. This is where Tiyatien Health's friends come to start anti-retrovirals (ARV), receive primary healthcare, refill their ARVs and other medications, and receive support and encouragement. Paper records are stacked on a desk. A scale sits on the ground. Ledgers are open on a table. Scraps of white paper serves as prescriptions. Othello, the extremely dedicated HEI Clinic Physician Assistant, usually sees all the patients, but on Thursday, he was sick, so I had to sit in for him.

Othello, our HEI Clinic Physician Assistant

Ms. R walked into the room with her 6 month old baby. My eyes lit up, seeing how much stronger she appears. Gia and I had just discharged her 2 weeks ago after a hospitalization for anorexia, anemia, and a new diagnosis of HIV. After meeting with our HIV Counseling and Testing Counselor as an inpatient, she agreed to initiation of ARVs. Ms. R returned to clinic to pick up her ARVs. She gained 6 lbs in 2 weeks, reported that she was eating and drinking well, and had no side effects from the ARVs. Most importantly, she has not missed one dose of her ARVs. She left with a follow up appointment in 1 month and a refill of her life-saving medications.

As I finished writing my clinic note and filling out the proper paperwork, Ms. L walked into the room. Her face stretched into a broad grin when she recognized me behind the desk. I had seen Ms. L about 10 days prior in HEI Clinic. She appeared ill, was breathing fast, and had some crackles in her right lung base. I admitted her for pneumonia, and she began antibiotics. Daily, Gia and I rounded on her, and slowly, she improved. By discharge, she was asking me to go home as she was ambulating, eating and drinking, and her crackles were no longer there. I had gone over her discharge medications and made her promise to come back to HEI Clinic in 3 days. She made good on her promise. My face also stretched in a broad grin when I saw her. She looked well and continued to take all her discharge antibiotics. Ms. L received a refill of her ARVs and asked me if I would be at HEI Clinic next month. Unfortunately, no, I told her. She frowned and asked whether I could visit her in Janzon, a forty-five minute drive away from Zwedru. I promised I would try. We exchanged the Liberian handshake, and then we hugged. We both had gigantic smiles on her faces.

I continue to hope that both Ms. R and Ms. L will take their ARVs and come to HEI Clinic monthly. Both of them are testament to the success of Tiyatien Health, its accompaniers, and the HEI Clinic.

Scenes from Martha Tubman Memorial Hospital

A few select photos from the Hospital:

Learning Microsoft

This past Monday and Wednesday, Gia and I held a staff training for the Liberian team. Before we arrived in Liberia, we had asked the Liberia team to let us know what subjects and skills they wanted us to help train them in. Resoundingly, the staff wanted to learn about computers. In the US, we take it for granted the availability of computers and the readily accessible and fast internet. Children now grow up with their own laptops, desktops, and the ability to surf the internet. By the time they are in middle school, most children can type. Here in Liberia, it is rare to find adults who know how to type, much less know how to turn on a computer; thus, we started holding biweekly trainings for our Tiyatien Health Liberian staff. This first week, we taught basics of the computer, including turning it on, navigating Microsoft XP, opening programs, and changing sizes of windows. We also taught them Microsoft Word. They are avid learners, and once they are trained, Gia and I are hopeful that they will continue to familiarize themselves with computer programs. Next week, we plan to train them in Microsoft Powerpoint. Ideally, we would love for our Liberian staff to have more access to computers, internet, and for them to each feel comfortable using a computer as this would help us build our capacity.

Cooking in Zwedru

Some scenes from Gia and my foray into cooking in Zwedru:

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?

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.

Our New Home

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.

“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.

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.