Monrovia — Until recently, the emergency room at Liberia's main hospital was "a place you came to die," says Dr. Braden Hexom, who teaches emergency medicine at New York's Mount Sinai School of Medicine. With perhaps the world's highest rate of newborn mortality, Liberia had not a single pediatrician. The hospital had no means of administering treatment intravenously. There was no imaging equipment – not even a simple x-ray machine.
Thanks in large part to the volunteers of Heartt - the Health Education and Relief Through Teaching network – all that is changing. Improving JFK Hospital in Monrovia, Liberia's capital, is the U.S.-based non-profit organization's initial focus to address the country's vast healthcare gap.
The needs are acute. After two decades of unrest, including 14 years of war among competing factions, Liberia has one of the world's poorest doctor-to-patient ratios and perhaps the highest rate of newborn mortality. About half the population of three million people suffer from malaria at any given time. Less than a third of children have been immunized against measles.
Since President Ellen Johnson Sirleaf's democratically elected government took office in 2006, the administration has boosted health spending, and Dr. Walter Gwenigale has won international praise as minister of health. But Liberia has been fighting challenges on all fronts, with scant resources, to rebuild national infrastructure. Besides the health crisis, there is an acute need for electricity, water and other essential services that were destroyed during the war and are central to improving health. Dr. Janis Tupesis, a Heartt volunteer from the University of Chicago medical school, was completing work at JFK on a patient's serious wound when the electricity went out. "We had to finish the job with a head lamp," Tupesis told a reporter for the university's website.
Dr. James A. Sirleaf, Heartt's chairman and the son of Johnson Sirleaf, founded the organization four years ago to help rebuild Liberia's health services by improving healthcare delivery and establishing partnerships with academic institutions to provide training and increase local capacity. JFK Hospital administrators say the Heartt volunteers have been key to the institution's rehabilitation.
In July, Heartt held its annual symposium and pre-departure workshop for its next group of medical volunteers at Brown University in the U.S. state of Rhode Island. More than three dozen physicians and other health professionals have been recruited to travel to Liberia this year to teach and mentor Liberians, while practicing and treating patients. Each new volunteer will spend about six weeks at JFK.
To prepare volunteers for their rotations, the pre-departure seminar covers topics such as the political climate and social practices of Liberia, techniques for diagnosing and managing malaria, and drug selection at JFK Hospital, given the restricted availability of medicines compared to the pharmacopeia of more developed countries. Symposium faculty, including emergency-care expert Hexom, also shared first-hand accounts and personal tips about working at JFK.
Heartt began four years ago in JFK's emergency department, where most patients came for initial care. The group has expanded to include programs in pediatrics, internal medicine and surgery, with a growing focus on training nurses and physician assistants. Volunteers were warned that they would often find themselves the most medically educated person available at the bedside.
Earlier in Monrovia, during one of his regular trips to JFK, Sirleaf, who is an emergency medicine specialist practicing and teaching at Connecticut's Bridgeport Hospital and the Yale-New Haven Hospital, talked about Heartt's rapid evolution from primarily treatment to treatment combined with training. "We realized," he said, "that sustainability can't come by providing treatment alone. To have the biggest impact, we can't just come and treat and leave."
Dr. Simon Kotlyar, director of global health in the department of emergency medicine at Yale University, praised Heartt's focus on the clinical education of doctors, nurses and physician assistants, and making JFK a teaching hospital. Visiting the hospital with Sirleaf, who recruited him as volunteer medical director of the Heartt initiative, Kotlyar said the program aims "to raise the clinical care capacity – but also to raise the capacity of the physicians and nurses here to serve as educators."
Kotlyar believes such an approach develops a hospital staff that becomes a critical national resource. "When they go out to train other providers in the community," he said, "they have a higher level of training that can trickle down to the mid-level providers." Central to Heartt's mission at JFK, he said, is "to raise the clinical-care capacity, but also to raise the capacity of the physicians and nurses here to serve as educators."
At this year's Heartt training symposium, malaria was a major topic. A disease rarely encountered by health professionals in North America, malaria is not only common but deadly in Liberia. International statistics showing that 60,000 children under five die from malaria each year in Liberia is thought to be substantially lower than the real number, due to challenges in data gathering in a country with few passable roads.
Kotlyar told this year's Heartt volunteers that factors in the high death rate includes a lack of access to healthcare and drugs, but also to misdiagnosis or receiving the wrong medications. He hopes that funders of Liberia's anti-malaria programs will devote more attention to training clinicians on distinguishing malaria from prevalent illnesses with similar symptoms, including fever, and on selecting the most effective medicines for particular circumstances.
Although insecticide-treated bed nets help prevent malaria, they are not always used or are used inefficiently, said Dr. Richard Moriarty, a professor of pediatrics at the University of Massachusetts. In Liberia's hot and humid climate, sleeping under bed nets can be uncomfortable, and although 49 percent of households have bed nets, only 26 percent of children are estimated to sleep under them. Therefore, it is vitally important that malaria be detected early and treated immediately, he said.
Six months ago, to address the lack of doctors specializing in children's illnesses, Heartt hired Nigerian pediatrician Emmanuel Okoh. With roughly half the Liberian population under the age of 25, he has his hands full. With the assistance of Heartt volunteers, Okoh launched the Chronic Illness Clinic, which was designed to provide follow-up care for children discharged from JFK. The new clinic's physicians, as in other Heartt-sponsored projects, will provide clinical education, as well as dispensing medication and identifying complications through outpatient services.
In 2008, JFK graduated its first nursing class since the war, and the training of physician's in also underway. Heartt is partnering with the University of Massachusetts medical school to develop a pediatrics curriculum for training the Liberian medical interns and other practitioners rotating through the pediatric department at the hospital. In addition, Heartt is creating an emergency medicine curriculum for physicians, physician assistants and nurses.
Thanks to institutional partnerships and donations, Heartt volunteers are now continuously resident at JFK. Each six-week volunteer has two weeks of orientation while working alongside the volunteer being replaced, and longer-term volunteers are being recruited. As the hospital that gets referrals of the sickest patients, as well as treating the population of the Monrovia area, patients at JFK are often at an advanced stage of illness.
In an interview at her JFK office, Dr. Wvannie Scott-McDonald, the hospital's CEO and administrator, said that Heartt has been central to rebuilding the facility and to spreading its teaching and clinical expertise throughout the country. Without the skills of the volunteers, she said, many hospital patients would not have had specialist treatment. And without the training component of Heartt's work, the education of the next generation of medical professionals would have been much more limited.
On a tour of the hospital, where construction seems perpetual, students and staff said the Heartt volunteers have taught essential skills. "I feel so proud when I'm triaging and coding a patient in the emergency department," said one. Local technicians have learned to use the new ultrasound machines Heartt brought as a cost-effective way to do internal imaging, and trainees are learning to service and maintain the equipment. Liberian nurses have returned from exile to teach, and they say their students are intelligent and lively, though most spent their childhoods on the run or in refugee camps in neighboring countries.
Sirleaf and Kotylar aim to continue to expand the work at JFK and beyond. Sirleaf's original vision of rebuilding the hospital has become a passion for extending health services across the country, through world-class teaching and learning. While numerous non-governmental organizations have come into Liberia to launch health projects, often after a brief acquaintance with the country and its needs, Kotylar says Heartt has a strategy, based on lengthy assessment accompanied by clinical experience, and has built an institutional infrastructure to expand cost effectively. Implementing the strategy, he says, depends on two factors: "Money, yes. Donations and grants are needed. But spending the money wisely, in the right way, is just as important."
Transparency is also critical, Sirleaf adds. "All NGOs should be transparent in what they spend and how they spend it," he said. "Metrics and budgets should be reported to a central authority" which can plan and prioritize to achieve Liberia's ambitious public health goals. Heartt, Sirleaf said, aims to lead the way in that responsibility, alongside its treating and teaching mission.