In this second installment of Dr. Polifka’s Africa journal, he describes his participation in medical education for the medical students and interns in the rudimentary training program at the John F Kennedy Medical Center in Liberia. For the entire country with a population of 3.4 million, there are only 52 physicians. Michael describes his personal transformation to a view that “all health care is local.” That’s how he feels change will happen and it’s how he’s decided to spend his time. See what you think.
Mark
Dr. Michael Polifka’s medical journal from Monrovia Liberia- March 2008
The medical ward had about seventy beds divided up into six bed wards. It was but 75% filled, not for lack of patients in the country but rather because of lack of any public funding or health insurance. With the profound lack of virtually all standard daily medical supplies the hospital had to resort to having most patients pay an upfront deposit for medicine before they could be admitted and then pay for every lab or x-ray test prior to it being done.
Some of the patients lived in or near the capital but many of the patients had been to other medical facilities in the country recently and had come to ‘the JFK’ for more advanced treatment; all were very sick. In one ward were mostly patients in their 40s and 50s, too young for the significant stroke, kidney disease or heart failure they had resulting from severe uncontrolled hypertension. The next was a room with older patients often with cancer presenting too late for effective treatment even if there were oncologists or surgeons available; there weren’t. The one starkly furnished room where there was up to date treatment available (from international sources) was the female AIDS ward; it was always full.The afternoon outpatient clinics were more of the same illnesses, severe hypertension, heart disease, pneumonia, and diabetes along with the more common intestinal parasites, typhoid fever and malaria (lots and lots of malaria). There are remarkably few patients with just aches and pains. My days are always full and satisfying, feeling that I have added a bit to the care of the patients being that day and to seen in the future.
Yesterday was eye opening to say the least. A 16 year old girl who had slipped into a coma the previous night was presented to me on morning hospital rounds. She had been slowly deteriorating for the past five days (she had walked into the hospital) and the cause unrecognized by all the nurses, med students, and interns that had seen her over that time. As I was about to begin a Socratic questioning of the medical students about the causes of coma, I noticed the IV fluid the patient was obtaining was dextrose water, apparently only that since admission and was certainly the cause of her condition.
My comments were direct but restrained, aimed at education during the last minute change in treatment that of course did nothing to change the expected outcome. She died in front of us. Through the day I found myself perseverating about the case, trying to grasp the magnitude of the problem. Where do you start? The immediate lesson to be taught about the IV fluid management was easy to present, but what about the bigger picture? Certainly being accusatory is useless at best; for the med students have all taken nine years to get to the 4th year of med school, with little in the way of textbooks, school closed every couple of months for undetermined amounts of time and no real clinical training. The interns all in their 40s have taken even more time to get to where they are, trying to learn without even the most basic clinical equipment to support them, and with few attending physicians to supervise and teach them. And there are but 52 physicians in the entire country, many of whom are elderly, hanging on hoping there will be someone soon to replace them.
Worldwide it is increasingly being recognized that real improvement in the developing world comes not from large grandiose plans (more often than not from those outside) but from those working locally. The task of returning this medical center to its prestigious level of two decades ago is a very large barrel to fill. Dr. Dennis and his small attending staff certainly have made major contributions in the past two years adding to the barrel, but there is still is so much to do. What we accomplished here is but a ladle-full added to that barrel, but I am impressed by the belief of my new friends here that this is a pail that can be filled. I have been privileged to add a few drops to it.
Michael