Built into the hillside, just bellow the mountain spring that supplies drinking water, and adjacent to the Episcopal Mission High School, St Timothy Hospital overlooks the town of Robersport. It is visible all the way from the beach, a white washed, concrete structure with blue lettering bearing the name of the original mission site and shuttered windows all in a line, like square portholes, also painted blue.
The nurses’ dormitory stands to the left. I am told that before the wars, this hospital was a primary site for nursing apprenticeship education. However, it was also always acknowledged to be "a hardship post", due to its remoteness and arguable degree of isolation. While perhaps not the most desirable location for those hoping to rub shoulders in Monrovia, Liberian nurses have a long history of coming to Grand Cape Mount, and to St. Timothy, to train.
Today, the dorms are not as full as they could be, should be, nor is the hospital. Staffing is limited, resources are scant, and utilization of services not maximized, creating a chicken before the egg conundrum. On one hand, to bolster the archaic technology and greatly expand staffing in the hospital and provide up to date, comprehensive services to patients, or the other, do we need first to be overwhelmed by patients, to justify this investment? The daily reality is a bad case of in between. Still, the core team of hospital workers shows up, day in and day out, to provide care to Cape Mountinians, regardless of the fact that they have not been paid for 3 months.
Our first day at St. Timothy was marked by an introduction meeting. We were presented to the staff by Dr. Garlo, the only doctor at this estimated 50 bed hospital. Dr. Garlo is one of the few remaining fully trained Liberian doctors. Estimates by various NGO groups vary, but there is agreement that there are less than 100 Liberian doctors in the entire country. That is about 1 doctor per every 135,000 people.
Keep in mind the cycles of mass exodus from this region over a 20 year period of conflict. The majority of direct clinical care and maintenance of the health infrastructure is still provided by external sources-the UN, missionaries, and NGO groups. While there are Liberians, and other West Africans employed by these groups, the majority are expatriate staff from “the western world”. Of note, the China is investing hugely in Liberia, paving roads, building schools, health clinics, and providing the one and only CT scan machine in the entire country. All this in exchange for fishing rights to Liberia’s coast line, land to clear cut for production of palm oil, and other crops. Many dynamics and implications here, but I’ll save it for another time.
When Dr. Garlo was appointed by the Ministry Of Health to St. Timothy, there had been no doctor in residence for over a year. He is responsible for the hospital, all the health clinics of Grand Cape Mount County, and for county wide health care administration. Like most of the clinical staff at Cape Mount, he boards at the hospital, and commutes to visit his family when possible. Along side Dr. Garlo is Mr. Quaye, or “Pa” Quaye, a Physicians Assistant who remained in Robertsport during the war when the entire community was sealed off from the rest of the country by rebel warlords. He was one of the few health care providers during that time of terror.
We waited in the courtyard of the hospital that first morning, along side serious faced staff members. They seemed unsure of us, or of our presence within their daily routine. We stood, scrub clad, with our pocket guides to tropical medicine, World Health Organization guidelines, and regional essential guides for drug treatment regimes, still sweating profusely from the climb up the hill. We had taken the foot path, a root tangled, dirt trail that is preferable because it is shaded by palms, instead of the winding, dusty road that requires 4WD low to make the ascent. Now, as the sweat ran and cooled down our backs, we were able to stare out at the green tree tops below, the strip of beach lacing the town's edge, and a never ending blue ocean, with tufting white caps breaking gently, far off shore.
Nurse Ahmi arrived, in pressed white, caring her signature ring of keys. A round woman with lovely, ink black eyes, and neat rows of braids pinned at the base of her short neck. She eyed us with contemplation and addressed her crew, "All my soldiers are still standing...the day is good". They seemed relaxed by her presence, and nodded, "Yah ma'am.", shaking hands all around.
When Dr. Garlo arrived, he led us all into the conference office, an airy room filled with sunlight and a large, rough wood table, surrounded by white plastic chairs in neat rows. The staff dutifully sat as we were presented. Our introductions were formal. When encouraged to speak, we tried to convey warmness, intentions for partnership, and optimism. My guess was the first impression made was...not the worst? I sensed "watch and wait" all around, and internally responded, "fair enough".
Relatively soon, the days began to take on a familiar enough routine. Arrival at the hospital as the early heat of the day begins. The concrete floors are being swept and mopped, the patients’ families shuffle in and out with basins of water, plastic buckets of every color, often balanced upon heads, to wash. Women wrapped in brightly printed lappa cloth, carry bars of soap, hair combs, and clean laundry off the outside clothes line. They wait in line to refill water buckets, fresh from their own bucket shower, with powder dotting collarbone lines, a dusky white contrast against deep black skin. Infants with skin and hair freshly oiled bounce on sagging mattresses, waving spoons into cups of rice water, gumming their hospital issued, sesame-seed covered breakfast “biscuit”. Malaria nets tied neatly above the cots flutter now and then, like ghosts from the night passed.
Rounds occur at each patient’s bedside. Pa Quaye, inspects the infants, then adults, flanked by the nurses who hold each chart, and scramble to rattle off vital signs when and if asked. Most assessments focus on things like “The baby sucking?” As in, is the child breastfeeding, or “This boy, he can drink?” to see if a child is able to keep fluids down. Meanwhile, patients waiting for the outpatient department line benches and vaguely engage in the daily education message, recited by a nurse tasked with addressing “ways that we prevent sexually transmitted infections”, or, “tell the real thing, so!…how we get this thing, TB”.
Rounds and treatment of outpatient illness are as much about discussing drugs to prescribe based on what is actually available as they are about care planning and case management. Quinine, first line of treatment for Malaria in Liberia, is on the order sheet for about 70% of the inpatients, despite their original presenting symptoms. However, it is a rare day that the hospital pharmacy has enough to dose all patients as ordered. Typically, once patients finish their 3 day IV course and need to be transitioned to tablets for 4 days to complete treatment, we ask their family to walk down the hill, go to the pharmacy in town to buy the medication.
Underlying, chronic pathologies such as anemia or malnutrition are addressed with pleas to care givers such as “mix some greens into this child’s fu fu, eh? He need it to make his blood strong. Blood be TOO low after Malaria, get the greens!” to which the mothers nod dutifully.
After rounds, depending on whether there are 1 or 2 nurses assigned to all 26 inpatients, I either commence with the passing of meds, mostly in the pediatrics ward, which comprises most of the inpatient population, or work in the free standing clinic that sees all the patients under 5 years old. From here, children are evaluated for their current complaint (usually fever, gastrointestinal illness, skin infections or abscesses, cough or rapid breathing).
If they meet criteria for admission, I send them across the courtyard to the pediatric ward with a yellow card to present to the nurse. I write the focused history, physical exam findings, admission orders for drugs and fluids, based on standardized guidelines for management of symptoms based on Integrated Management of Childhood and Neonatal Illness (IMNCI) protocols. This set of treatment protocols are designed for use at the community clinic level. Clinic staff are trained to follow step by step assessment questions, and make basic clinical observations to recognize danger signs for severe disease such as dangerously high respiratory rates, chest indrawing, fever measured beyond a certain point, convulsions, signs for severe dehydration.
I myself can’t help but couple these guidelines with a differential based on health history and physical exam. I write the protocol orders, then call the on call MD or PA if I want to alter or modify the orders to prevent what I worry might be excessive use of antibiotics. Still, I am learning how quickly these children get sick, very sick. I understand why we treat a fever, or refusal to breastfeed for a day, so aggressively.
The non-admits receive treatment, a prescription to take to the pharmacy. If their reason for coming is more of a return, follow up visit, we weigh the children, plot their growth on their Road to Health Cards, and usually I counsel them to promote nutrition and other behaviors for good health.We discuss hand washing and hygiene (rub your hands fast while someone pours from the water scoop for you, dipping hands into the bucket does not wash away the dirt, cover your water basins, treat your latrines, don’t allow people to pee pee or poo poo in the yards, make them go off to the side).
I make a big production about "the power" of green leafy vegetables, and foods with color (mango-called plum, avocado-called butter pear) and how to crush them, mix into the rice porridge. We discuss that children are like chickens, that they need to eat frequent, small meals, 5 or more times a day, not one big plate of rice, set on the floor, in the dark of the morning or dusk of night. We discuss that it takes time to feed children, that you actually have to put the food to their months, feed them “actively”…that otherwise they will not take in as much food, as many calories, or complementary foods.
We discuss breastfeeding, how it is a thing that even a poor mother can give to her child, valuable for good health, more than any money. We discuss and practice making homemade rehydration solutions-boil the water, cool it, let the child sip it, from a clean cup or spoon. If the child likes, add a little coconut water. We review the vaccine schedules, and I spend a lot of time listening to the practices of “country medicine”, and other traditional treatments and practices. Most infants have tiny metal bracelets, bands of thread, little woven string basket charms, or other emblems for protection knotted around their waists, beneath their diaper cloths, or around their necks.
I look at these young, thin, sweating and worn mothers, who offer their backs and breasts to carry and comfort their infants. I wonder, as I often do at home, at the disconnect between what I am asking that people add or change about their daily routine, the benefits that these things could bring, and what is realistic for them to consider. I know that many of these mothers have been up since before light, to haul wood and water, to prepare food, to smoke and then sell fish, to walk 5 or more kilometers to come to their clinic visit, have climbed the hill, carrying 1 or 2 children, and are now sweltering on a wooden bench, fanning themselves. I know that some have “a touch” of Malaria themselves, are anemic, that they likely eat last from the family pot, once a day.
By 3 o’clock, a calm settles over the hospital campus. Peak temperature for the day has set in, and the sun reflects off the tin roof. The glare reflects off the large rocks the line and holds together the dirt road. Funny shadows are cast across the cement courtyard where brightly colored laundry drip dries from clothes lines that zig zag between the support pillars.Socks, children’s diaper covers, and t-shirts bearing the logo and names of American Little League teams, Turkey Trot 5k fundraisers, and other clothes items that make their way across the Atlantic to African clothes markets fill the space between squares of lappa cloth. This cloth, patterned cotton prints in bright, often geometric shapes, is worn as skirts and head wraps, used as blankets for newborns, as diapers for infants, to wipe noses and children’s faces, to lift away hot pot lids, and to cover the mattresses of the archaic hospital beds inside.
At this point, morning medications have been “served” by the nurses, and new admissions have been received from the outpatient clinics or ER. New IV lines have been placed, the corresponding wailing has ceased. The pharmacy has dispensed small zip lock bags of pills through their grated window, with slash marks made care fully to indicate taking the tablets 1-1, as in one in the morning, one at night, or 1-1-1-, morning, noon and night. The closet room used as a laboratory, where malria smears are interpreted and blood samples are spun down to be measure hemoglobin levels, is now locked and closed. If a new patient arrives, through the emergency area or otherwise, the nursing staff will have to call the lab tech on his cell phone and hope that he will come before rounds the next morning. The clinic's bleacher style benches are now empty, save for the stray person that has chosen to stay and sleep in the shade of the covered hallways.
The adult inpatients hitch up their hospital gowns, maybe put on a t-shirt over top, and wheel their IV poles or carry their urinary catheter bags in order to go stroll outside. They sit on benches or the front cement steps, trying to feel some breeze or movement of air. They gossip and watch foot traffic on the road below. Sometimes they comment on the state of the ocean, further on, towards the horizon. If there are visible white caps, or the sky begins to darken with an impending storm, they might remark, “the sea, its troubled today”.
Inside, on the pediatric ward, the infants sleep while their IV medications infuse; yellow colored potions roll from the drip chambers, down the tubing, bringing “science medicine” directly into portals placed painstakingly into these tiny arms and hands. Their mothers snooze beside them in bed, periodically swatting away flies. The nurses sit down for perhaps the first time, wipe their foreheads and upper lips, and begin to write out lists for the next round of medications due. The periodically glance at their cell phones, hoping for news or a familiar voice, knowing it will be 14 long days before time off to see their children or family again.
The hospital support staff-the broad chested, toothless women who boil enormous kettles of rice in the kitchen, the old man who drags a mop across the concrete floors, the ambulance driver, and registrers can be found napping on wooden benches, beneath trees, or can be seen walking slowly, down the hill, heading home for the day. Some remove plastic bowls from tucked away corners and eat the midday meal of rice, dry fish, and red palm oil.
Every thing seems to move slowly or even stand still; between the heat and effort spent to complete the morning routine, even the roosters are subdued, and take pause from their otherwise incessant squacking. At the nurses dorm it is also quiet, save for the sound of a radio, bringing BBC Africa news updates detailing the siege in Abijan, or the declaration of Libia’s no fly zone. Smoke curls from behind the building, where someone has lit a coal pot fire, signaling that the night shift crew is now awake, and preparing to cook, do laundry, and cold iron press their uniforms. The day seems to be ending, beginning, and staying the same all at once.
The nurses’ dormitory stands to the left. I am told that before the wars, this hospital was a primary site for nursing apprenticeship education. However, it was also always acknowledged to be "a hardship post", due to its remoteness and arguable degree of isolation. While perhaps not the most desirable location for those hoping to rub shoulders in Monrovia, Liberian nurses have a long history of coming to Grand Cape Mount, and to St. Timothy, to train.
Today, the dorms are not as full as they could be, should be, nor is the hospital. Staffing is limited, resources are scant, and utilization of services not maximized, creating a chicken before the egg conundrum. On one hand, to bolster the archaic technology and greatly expand staffing in the hospital and provide up to date, comprehensive services to patients, or the other, do we need first to be overwhelmed by patients, to justify this investment? The daily reality is a bad case of in between. Still, the core team of hospital workers shows up, day in and day out, to provide care to Cape Mountinians, regardless of the fact that they have not been paid for 3 months.
Our first day at St. Timothy was marked by an introduction meeting. We were presented to the staff by Dr. Garlo, the only doctor at this estimated 50 bed hospital. Dr. Garlo is one of the few remaining fully trained Liberian doctors. Estimates by various NGO groups vary, but there is agreement that there are less than 100 Liberian doctors in the entire country. That is about 1 doctor per every 135,000 people.
Keep in mind the cycles of mass exodus from this region over a 20 year period of conflict. The majority of direct clinical care and maintenance of the health infrastructure is still provided by external sources-the UN, missionaries, and NGO groups. While there are Liberians, and other West Africans employed by these groups, the majority are expatriate staff from “the western world”. Of note, the China is investing hugely in Liberia, paving roads, building schools, health clinics, and providing the one and only CT scan machine in the entire country. All this in exchange for fishing rights to Liberia’s coast line, land to clear cut for production of palm oil, and other crops. Many dynamics and implications here, but I’ll save it for another time.
When Dr. Garlo was appointed by the Ministry Of Health to St. Timothy, there had been no doctor in residence for over a year. He is responsible for the hospital, all the health clinics of Grand Cape Mount County, and for county wide health care administration. Like most of the clinical staff at Cape Mount, he boards at the hospital, and commutes to visit his family when possible. Along side Dr. Garlo is Mr. Quaye, or “Pa” Quaye, a Physicians Assistant who remained in Robertsport during the war when the entire community was sealed off from the rest of the country by rebel warlords. He was one of the few health care providers during that time of terror.
We waited in the courtyard of the hospital that first morning, along side serious faced staff members. They seemed unsure of us, or of our presence within their daily routine. We stood, scrub clad, with our pocket guides to tropical medicine, World Health Organization guidelines, and regional essential guides for drug treatment regimes, still sweating profusely from the climb up the hill. We had taken the foot path, a root tangled, dirt trail that is preferable because it is shaded by palms, instead of the winding, dusty road that requires 4WD low to make the ascent. Now, as the sweat ran and cooled down our backs, we were able to stare out at the green tree tops below, the strip of beach lacing the town's edge, and a never ending blue ocean, with tufting white caps breaking gently, far off shore.
Nurse Ahmi arrived, in pressed white, caring her signature ring of keys. A round woman with lovely, ink black eyes, and neat rows of braids pinned at the base of her short neck. She eyed us with contemplation and addressed her crew, "All my soldiers are still standing...the day is good". They seemed relaxed by her presence, and nodded, "Yah ma'am.", shaking hands all around.
When Dr. Garlo arrived, he led us all into the conference office, an airy room filled with sunlight and a large, rough wood table, surrounded by white plastic chairs in neat rows. The staff dutifully sat as we were presented. Our introductions were formal. When encouraged to speak, we tried to convey warmness, intentions for partnership, and optimism. My guess was the first impression made was...not the worst? I sensed "watch and wait" all around, and internally responded, "fair enough".
Relatively soon, the days began to take on a familiar enough routine. Arrival at the hospital as the early heat of the day begins. The concrete floors are being swept and mopped, the patients’ families shuffle in and out with basins of water, plastic buckets of every color, often balanced upon heads, to wash. Women wrapped in brightly printed lappa cloth, carry bars of soap, hair combs, and clean laundry off the outside clothes line. They wait in line to refill water buckets, fresh from their own bucket shower, with powder dotting collarbone lines, a dusky white contrast against deep black skin. Infants with skin and hair freshly oiled bounce on sagging mattresses, waving spoons into cups of rice water, gumming their hospital issued, sesame-seed covered breakfast “biscuit”. Malaria nets tied neatly above the cots flutter now and then, like ghosts from the night passed.
Rounds occur at each patient’s bedside. Pa Quaye, inspects the infants, then adults, flanked by the nurses who hold each chart, and scramble to rattle off vital signs when and if asked. Most assessments focus on things like “The baby sucking?” As in, is the child breastfeeding, or “This boy, he can drink?” to see if a child is able to keep fluids down. Meanwhile, patients waiting for the outpatient department line benches and vaguely engage in the daily education message, recited by a nurse tasked with addressing “ways that we prevent sexually transmitted infections”, or, “tell the real thing, so!…how we get this thing, TB”.
Rounds and treatment of outpatient illness are as much about discussing drugs to prescribe based on what is actually available as they are about care planning and case management. Quinine, first line of treatment for Malaria in Liberia, is on the order sheet for about 70% of the inpatients, despite their original presenting symptoms. However, it is a rare day that the hospital pharmacy has enough to dose all patients as ordered. Typically, once patients finish their 3 day IV course and need to be transitioned to tablets for 4 days to complete treatment, we ask their family to walk down the hill, go to the pharmacy in town to buy the medication.
Underlying, chronic pathologies such as anemia or malnutrition are addressed with pleas to care givers such as “mix some greens into this child’s fu fu, eh? He need it to make his blood strong. Blood be TOO low after Malaria, get the greens!” to which the mothers nod dutifully.
After rounds, depending on whether there are 1 or 2 nurses assigned to all 26 inpatients, I either commence with the passing of meds, mostly in the pediatrics ward, which comprises most of the inpatient population, or work in the free standing clinic that sees all the patients under 5 years old. From here, children are evaluated for their current complaint (usually fever, gastrointestinal illness, skin infections or abscesses, cough or rapid breathing).
If they meet criteria for admission, I send them across the courtyard to the pediatric ward with a yellow card to present to the nurse. I write the focused history, physical exam findings, admission orders for drugs and fluids, based on standardized guidelines for management of symptoms based on Integrated Management of Childhood and Neonatal Illness (IMNCI) protocols. This set of treatment protocols are designed for use at the community clinic level. Clinic staff are trained to follow step by step assessment questions, and make basic clinical observations to recognize danger signs for severe disease such as dangerously high respiratory rates, chest indrawing, fever measured beyond a certain point, convulsions, signs for severe dehydration.
I myself can’t help but couple these guidelines with a differential based on health history and physical exam. I write the protocol orders, then call the on call MD or PA if I want to alter or modify the orders to prevent what I worry might be excessive use of antibiotics. Still, I am learning how quickly these children get sick, very sick. I understand why we treat a fever, or refusal to breastfeed for a day, so aggressively.
The non-admits receive treatment, a prescription to take to the pharmacy. If their reason for coming is more of a return, follow up visit, we weigh the children, plot their growth on their Road to Health Cards, and usually I counsel them to promote nutrition and other behaviors for good health.We discuss hand washing and hygiene (rub your hands fast while someone pours from the water scoop for you, dipping hands into the bucket does not wash away the dirt, cover your water basins, treat your latrines, don’t allow people to pee pee or poo poo in the yards, make them go off to the side).
I make a big production about "the power" of green leafy vegetables, and foods with color (mango-called plum, avocado-called butter pear) and how to crush them, mix into the rice porridge. We discuss that children are like chickens, that they need to eat frequent, small meals, 5 or more times a day, not one big plate of rice, set on the floor, in the dark of the morning or dusk of night. We discuss that it takes time to feed children, that you actually have to put the food to their months, feed them “actively”…that otherwise they will not take in as much food, as many calories, or complementary foods.
We discuss breastfeeding, how it is a thing that even a poor mother can give to her child, valuable for good health, more than any money. We discuss and practice making homemade rehydration solutions-boil the water, cool it, let the child sip it, from a clean cup or spoon. If the child likes, add a little coconut water. We review the vaccine schedules, and I spend a lot of time listening to the practices of “country medicine”, and other traditional treatments and practices. Most infants have tiny metal bracelets, bands of thread, little woven string basket charms, or other emblems for protection knotted around their waists, beneath their diaper cloths, or around their necks.
I look at these young, thin, sweating and worn mothers, who offer their backs and breasts to carry and comfort their infants. I wonder, as I often do at home, at the disconnect between what I am asking that people add or change about their daily routine, the benefits that these things could bring, and what is realistic for them to consider. I know that many of these mothers have been up since before light, to haul wood and water, to prepare food, to smoke and then sell fish, to walk 5 or more kilometers to come to their clinic visit, have climbed the hill, carrying 1 or 2 children, and are now sweltering on a wooden bench, fanning themselves. I know that some have “a touch” of Malaria themselves, are anemic, that they likely eat last from the family pot, once a day.
At this point, morning medications have been “served” by the nurses, and new admissions have been received from the outpatient clinics or ER. New IV lines have been placed, the corresponding wailing has ceased. The pharmacy has dispensed small zip lock bags of pills through their grated window, with slash marks made care fully to indicate taking the tablets 1-1, as in one in the morning, one at night, or 1-1-1-, morning, noon and night. The closet room used as a laboratory, where malria smears are interpreted and blood samples are spun down to be measure hemoglobin levels, is now locked and closed. If a new patient arrives, through the emergency area or otherwise, the nursing staff will have to call the lab tech on his cell phone and hope that he will come before rounds the next morning. The clinic's bleacher style benches are now empty, save for the stray person that has chosen to stay and sleep in the shade of the covered hallways.
The adult inpatients hitch up their hospital gowns, maybe put on a t-shirt over top, and wheel their IV poles or carry their urinary catheter bags in order to go stroll outside. They sit on benches or the front cement steps, trying to feel some breeze or movement of air. They gossip and watch foot traffic on the road below. Sometimes they comment on the state of the ocean, further on, towards the horizon. If there are visible white caps, or the sky begins to darken with an impending storm, they might remark, “the sea, its troubled today”.
Inside, on the pediatric ward, the infants sleep while their IV medications infuse; yellow colored potions roll from the drip chambers, down the tubing, bringing “science medicine” directly into portals placed painstakingly into these tiny arms and hands. Their mothers snooze beside them in bed, periodically swatting away flies. The nurses sit down for perhaps the first time, wipe their foreheads and upper lips, and begin to write out lists for the next round of medications due. The periodically glance at their cell phones, hoping for news or a familiar voice, knowing it will be 14 long days before time off to see their children or family again.
The hospital support staff-the broad chested, toothless women who boil enormous kettles of rice in the kitchen, the old man who drags a mop across the concrete floors, the ambulance driver, and registrers can be found napping on wooden benches, beneath trees, or can be seen walking slowly, down the hill, heading home for the day. Some remove plastic bowls from tucked away corners and eat the midday meal of rice, dry fish, and red palm oil.
Every thing seems to move slowly or even stand still; between the heat and effort spent to complete the morning routine, even the roosters are subdued, and take pause from their otherwise incessant squacking. At the nurses dorm it is also quiet, save for the sound of a radio, bringing BBC Africa news updates detailing the siege in Abijan, or the declaration of Libia’s no fly zone. Smoke curls from behind the building, where someone has lit a coal pot fire, signaling that the night shift crew is now awake, and preparing to cook, do laundry, and cold iron press their uniforms. The day seems to be ending, beginning, and staying the same all at once.
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