As I reflect on my last few months at Phebe Hospital in Bong County, Liberia, my thoughts are drawn to particular patients who are hard to forget, like:
- The 6-year-old boy who burned his leg severely falling into a fire during a seizure. His family spent two months seeking care elsewhere; he spent another two months in the hospital recovering from surgery.
- The developmentally delayed, severely malnourished 1-year-old, who weighed 4 kg (8.8 lbs; the average weight of a 2-week old) when I first met him one Wednesday afternoon.
- The 4-year-old girl with malaria, treated in the hospital after experiencing fevers and seizures. She was covered in chalk after being treated with herbs in the village.
- The 6-month-old girl who arrived in the emergency room with a florid full body rash. Her parents had been treating her with a cream of herbs mixed into zinc oxide.
It is amazing how quickly I adjusted to hearing stories like these, which would seem so far-fetched if heard in the Boston Children’s emergency room. However, an overriding theme that seemed to link a lot of my patients’ stories was shopping around for local remedies before coming to Phebe.
In a country whose total expenditure on health per capita is $88 (in 2013) — one still reeling from years of civil war and a devastating Ebola epidemic — it seems a luxury to even consider the need for primary health care. But when primary care doesn’t exist, patients have no chance to develop a trusting relationship with a health care provider.
Thus, when a family’s child is ill, they often pursue local or folk remedies first, seeking formal medical care only as a last resort or when the illness reaches the point of urgency.
When they do appear for care, they’re often first met with blame. “Why did you wait this long to come in,” frustrated doctors and nurses exclaim. “How did you let this happen to your child?”
Expectation of a chilly welcome is compounded by the impression that the hospital is a place to go to die. Unfortunately, to some degree there are statistics to back this notion. Liberia’s infant and under 5 mortality rates are 54 and 94 per 1000 live births, respectively. And because they wait so long, patients occasionally arrive at the hospital when they are beyond intervention.
Signs of change
Shortly before I started working at Phebe, the 2nd year pediatric residents took it upon themselves to start a primary care clinic for children with chronic conditions. Patients with asthma, seizure disorders, rheumatic heart disease and sickle cell disease are told to come soon after a hospital discharge, and are then scheduled to return for frequent follow-up visits. By engaging families early and encouraging them to come often, the clinic is building relationships and providing much needed anticipatory guidance and counseling.
Through this clinic, these children now receive the appropriate pediatric care, reducing the risk that a child will arrive in our emergency room with an acute exacerbation that has progressed beyond intervention. Case in point: The team recently caught a developing case of avascular necrosis of the femoral head in a sickle cell patient who would otherwise have had unsuccessful treatments at home.
It is fair to assume that most parents want to do the best (however that is defined) for their children. Where they feel they cannot trust medical providers and institutions, they will likely provide care at home before turning to the formal health sector. This is why it is not enough for systems to provide just emergency health services. Primary health care is of paramount importance, but it must be delivered with compassionate, caring support. With their chronic care clinic, the residents at Phebe Hospital have created a model for the rest of the country. And I have seen first hand how every family that walks in is grateful for the counseling, guidance and care they provide.
Ophelia Adipa, MD, is a fellow in the Global Health Program at Boston Children’s Hospital. Over the course of the fellowship she has traveled to Mbale, Uganda as a consultant pediatrician at the CURE Children’s hospital of Uganda and was in Liberia as pediatric faculty, teaching and mentoring residents and interns. Her time was split between the John F. Kennedy Medical Center in Monrovia and Phebe hospital in Suakoko. Before joining Boston Children’s, she completed her pediatric residency at the Children’s National Medical Center and had global health experiences in Ghana, Senegal and Nicaragua.