Background to visit.

The outcome of two visits in January & May 2008, to 3 hospitals in Liberia’s capital Monrovia revealed a significant need for two major resources in the attempt to achieve a reduction in the lifetime risk of maternal mortality rate of 1:8. These resources are:-

1. Appropriate medications to treat the 2 main causes of maternal death, eclampsia and post partum haemorrhage.

2. Training for midwives and TBAs who, during and since the civil war have tried to maintain a service to the women in the absence of medical staff.

In September, the medications started arriving in the form of 2000 ampoules of Magnesium Sulphate to treat eclampsia and 600 doses of Cytotec, (brought with us) to treat PPH. It had been agreed that both drugs were to be shared between the three hospitals, Redemption, JFK & ELWA, with an absolute agreement that no woman is to be asked for payment for either drug.

For the second requirement, that of training, the charity recruited a Consultant Obstetrician, Dr Lisa Avery, Assistant Professor of Obstetrics at Manitoba University Hospital. Lisa joined me and one of the Cardiff & Vale Maternity Healthcare Assistants Anne O’Regan on this latest visit.

It had been hoped to visit a rural area during the visit but the weather proved to be challenging, with the wet season bowing out with thunder, spectacular lightning displays and torrential downpours which almost brought several roads to a standstill. The first of these storms happened on our very first night in Liberia.

Thursday 2nd October The visit began with a meeting at the Ministry of Health where Dr Lisa Avery’s documents had been sent 2 months before our arrival in readiness for her clinical input. Unfortunately the necessary process had not been undertaken as we would have hoped and a delay occurred, but we were assured that everything would be sorted by Monday 6th October. We then visited the Clinton Foundation offices at the Ministry of Health where we met with Mrs Denise Walsh, the Chief Nurse of the Redemption Hospital who had been instrumental in co-ordinating the safe arrival of the Magnesium Sulphate and the workshops during the May visit. From the Ministry we travelled to the Redemption Hospital where we were shown around the very busy hospital, meeting with old friends from previous visits and delivering items such as the Cytotec to the pharmacy and speaking at length to the Chief Pharmacist. In the post natal ward, we met women who had been treated with the medicines which we had sent, including a woman who had been in an eclampsia induced coma for 2 days. Sadly her baby had died but she had recovered sufficiently to speak to us. One woman was clearly unwell, experiencing rigors with a very high temperature, in these tropical areas assumed to be caused by malaria.

Friday 3rd October The accommodation which had been assured as being “of European Standards” turned out not to be so and today we moved to the guest house which we had used during the January visit. In the evening we were hosted by Mrs Walsh where we met with individuals who are working with NGOs in areas such as HIV/AIDS and a Senior Doctor in Emergency Medicine at Redemption.

Saturday 4th brought an opportunity to visit ELWA hospital, where we met with Dr Dada, one of only 2 Consultant Obstetricians in Liberia serving a population of 3.3million. There are only 27 practicing doctors in the country, a further legacy of the civil war.

Sunday 5th brought problems for the three of us in the form of a stomach bug which pretty much resolved within 24hrs, but confined us to the accommodation allowing plans and initial impressions to be discussed.

Monday 6th October took us back to the Ministry of Health where the issue of Lisa’s papers had still to be resolved, with requests for further documents which were still in Canada. From there we travelled to the Island Hospital, which is run by MSF and cares for sick children including newborns. The capacity of the hospital is 168, but the reality is that they are currently caring for more than 280 children. This makes bed sharing necessary, with 2 or even 3 children to a bed. No child is turned away, however the conditions particularly in the overflow area,( a large open tent) leave one wondering how staff manage to work in such circumstances. There is no privacy for the children or for the staff undertaking delicate procedures on sick little people. Distraught parents grieve openly for their children. MSF is going to pull out of Liberia at the end of 2009, as long term care is not strictly their remit, so there is great concern about who will care for these children, especially those who have been offered and commenced on long term ARV treatment for conditions such as HIV/AIDS.

Tuesday 7th brought news from the Ministry that Lisa cannot work in the country without further papers which are in Canada! However this did not prevent Lisa collecting useful data and reviewing the admission documentation. Further torrential downpours followed with the main external corridor of Redemption looking like the Colorado River, yet everyone just stood watching what was for them, a normal natural event. For us the spectacular overflows under which children took off their clothes and ran around having fun were something rarely seen in the UK. When the rain eased we travelled to JFK Hospital where we delivered the 650 ampoules of Magnesium Sulphate and Cytotec to Dr Ujah Lavinus the Senior Pharmacist. He then showed us a wipe clean board in the public area of the hospital where every donated drug is listed. He explained that this enables families to see what they should and should not be expected to pay for. Happily, Magnesium Sulphate and Cytotec have now been added to this list. In Redemption Hospital nobody pays for medicines, but in JFK & ELWA, some are free and others have to be paid for.

In the evening we met with Mrs Lucy Page who has set up a Community Empowerment Programme, which supports women who have experienced domestic violence, a major problem in Liberia. Amazingly Lucy has been instrumental in setting up a perpetrators programme. This whole programme is funded by the UNFPA, although Lucy acknowledged that such projects had to become self funding in the future, as NGOs will eventually pull out of Liberia and preparations have to be in place for a seamless transfer of ownership.

Wednesday 8th brought our last day and the opportunity to return to ELWA Hospital to deliver Magnesium Sulphate & Cytotec directly to the Chief Pharmacist and the Hospital Administrator. This was an opportunity for me to reinforce the condition of no payment for drugs donated by our charity. Each of the three hospitals is going to send a monthly summary of usage so that we can ensure a constant supply of both lifesaving drugs. From ELWA, we visited the local school and their Headmaster Mr Daniel Nyon, where we received a rapturous welcome. Daniel explained that the parents of some of the children had died either during the war or they had lost their mothers during pregnancy and/or childbirth. The school is trying to provide a meal for the children as many are arriving for school obviously hungry and falling asleep because they have not eaten. The impact of maternal mortality stretches far and wide.

A further shipment, this time of antibiotics had arrived at the airport and arrangements were put in place by Mrs Denise Walsh to collect and share the shipment at the same time as we were to be at the airport for our departure. The 235kgs parcel contained 1000 doses of each of the following... Benzyl-penicillin, Gentamycin, Ampicillin & Metronidazole, plus surgical instruments for undertaking Caesarean Sections.

At 18.00hrs our plane took off for Brussels and then London. All agreed that despite the problems, the visit had been very worthwhile with major insight into working in a resource poor environment and a greater appreciation of the healthcare provision in the UK. It was however, felt necessary on our return, to communicate our concerns regarding the management of Lisa’s work permit as she wishes to return to Liberia in the spring for a much longer visit.

In conclusion, it is clear that Objective 1, that of providing the necessary medications has been achieved and will be sustained. Objective 2 will take a great deal more work to ensure that the western clinicians who wish to work in Liberia will be able to do so with the minimum of obstacles, thus providing the maximum of experience and much needed training. This hopefully will, in years to come and with our help, contribute to Liberia ultimately becoming self sufficient in healthcare for its citizens.

ANGELA GORMAN - 14TH OCTOBER 2008.