zondag 5 augustus 2018

Cancer Policy in Liberia : preparatory visit, July 3-5th

Brussels Airlines dropped me in the middle of the rain.
Airport control was chaotic as could be expected but I succeeded to find a successful track to my luggage. My suitcase had already been taken from the belt, but theft was prevented by checking the tag at the exit.
My daughter had told me the story of two doctors who took a common taxi at an African airport and they never showed up again.
Being welcomed by my name on a sign hold up by a driver and accompanying car, felt as a first guarantee for safety within a country that had suffered civil war and Ebola for decades.

As many West African countries, Liberia had been a transit point in slavery transport. 

In the beginning of the 19th century, relieved black American slaves came back to Liberia to establish firstly an American country and then an independent state oriented to American structures and values.
Until now the tension between the native Liberians (90%) and the Afro Americans is still an issue.
During the last two centuries, Liberia has always been exploited and abused by other countries through poorly negotiated contracts because of their mining products (rubber and others).
It was only in the sixties that native Liberians obtained the right to vote and in the nineties and in the beginning of the 3rd millennium a terrifying civil war occurred over the country.
One of the former presidents Samuel Doe was killed by Prince Johnson in a cruel way and the government of Charles Taylor, lasting until 2006, was nothing less than an authoritarian military state.
 He was recently condemned for crimes against humanity in The Hague.
It took until the presidency of Mrs. Ellen Johnson, as the first female president in Africa, in 2006, that a peaceful transition to democracy occurred.
She came from the World Bank and established at least on the political side a more stable government but economic development was almost completely destroyed by the Ebola crisis in 2014.
Recently her party lost the elections and since one year a famous formal football player, George Weah, has taken the highest position in the country.

On Wednesday morning the same driver posted me at the Ministry of Health.

I was welcomed by Florence -I thought Nightingale- but she died a long time ago, or Griffith- but her nails where short cut- and it took me a few rehearsals to remember that her last name was Yahnquee Kiatamba.

Beside Zoe Doe, she was part of the NCD team headed by Dr Fred Amegashie, a distinct cell within the Ministery of Health responsible for the management of Non Communicable Disease as diabetes, hypertension, COPD and cancer.
At the occasion of the Health Policy program in the Tropical Institute of Antwerp, I met Vera Mussah, head of the PBF unit of the Liberian Ministery, and she created the opportunity for a mission of our team focused on cancer policy in Liberia.

During the following interviews, I would learn that the last name revealed whether people were from an Afro-American background (10%) or a native Liberian background (90%).
At this moment -writing the story- the guardian who had started to shout to all the drivers who tried to find a spot at the hotel parking, came to me a little hesitating to request whether I could move a little bit to the left.
I presumed he had waited for more than half an hour to dare chasing me away and I rewarded his courage by moving friendly to the place he designed me.
Anyway, short pants and a white skin still makes the difference.

Florence guided me to the suburbs of the ministerial kingdom with the request whether I could have a short talk with Mrs. Jallah, educated as a gynaecologist.
She didn’t seem to have the right position or credentials to pass the bureaucracy and while going back to her office she suddenly was called back that the minister was available to see us.
All the barriers fell down until we arrived at the door of the minister’s office :" strictly forbidden to take electronic devices within the office.”
A few urgent matters preceded us in the waiting queue until we were welcomed by Mrs. 
At the end of my 2-days interview itinerary, I would never had postulated that the ambition of the project was to establish Liberia as an example for cancer policy and her slightly cynical look at the occasion of my remark, taught me that my cheap buy-in wasn’t really appreciated.

As I would learn in the following interviews, my introduction about my professional background was politely accepted but not more than a step over to the presentation of my dialogue partner’s history, beliefs, ideas and intentions.
The minister wanted to establish five or six ambulatory cancer centres in the country for prevention, counselling, screening, early diagnosis and chemotherapy treatment. She was in favour of independent small cancer centres as a kernel of expertise from where people could be referred to hospitals if necessary for example in case of surgery.
She referred me to Dr. Ann Marie Beddoe, an American gynaecologist who was doing some developing work in the JFK University Hospital for many years.
Mrs Jallah reassured access of me to her the same day by giving her an instant call.

The minister-assistant of prevention, Joyce Sherman, seemed to have no intense connection with the cancer policy.
She was more specific about programs on diabetic education and the delivery of HPV-vaccines to 14/16 years old girls.
She had worked for the WHO, USAID and since twelve years for the Liberian government.
She had a bachelor in nursing with an attention for public and child health.
She emphasised that the initiatives concerning cancer were fragmented and the aim was to analyse what was already there and then connecting the dots.
“There is no lack of evidence and nice policy documents”, she emphasised : “but it all blocks at the level of implementation.”
90% of the health budget of Liberia was spent on the pay of employees and administration. So only 10% was available for service delivery.
We had to realise that all improvement in infrastructure, education and quality had to be funded by third parties.
At this moment at JFK, a 5-million-dollar medical image center with MRI and CT was built with American money.

Driving from the hotel to the ministry, I remembered the construction of a huge new building for government agencies, sponsored by the Chinese and later the Japanese would welcome us in the JFK building for maternal care: the international competition for conquering Africa by development aid….

One hour later, again we had to pass the initial barrier of bureaucracy to meet Dr. Kaieh, the chief medical officer of the Ministry of Health.
Although it seemed to me that Florence had made appointments with all these responsible people, nevertheless every time we were welcomed as an unexpected guest.
It seemed that 20 minutes of humble waiting was building up a minimum level of confidence to be accepted for a visit.

Entering the office of Dr. Kaieh was like entering a world of rewards an certificates of high standard education with a kind of military flavour due to his tight suit.

He tolerated a short introduction of myself and then he referred me to a picture on the wall with a woman and a young boy lying on a bed.

“That’s why I’m here”, he started his story : “My mother was blind at one eye and I was mocked for that at school. She had had bacterial conjunctivitis.
Although we were poor and there was no perspective for university, I promised my mother I would become a doctor and travel in Liberia from city to city to deliver to the people convenient care.
When I had finished high school, I had no opportunity to obtain a master’s degree or to become a medical doctor as I had dreamed.
So, I started to do voluntary work in hospitals such as cleaning, until I was noticed by a surgeon, dr Stevenson, who was surprised I was spying his clinical work in the operation theatre. He offered me to pay for obtaining a university degree but unfortunately, he died after two years.
But I got a scholarship to have a medical education in the United States where I obtained my medical degree from 1988 to 1995.
In the meantime, my mother had died during the civil war in 1994.

After graduation, I came back to Liberia and worked at JFK, and from 1998 to 2001 I was medical director at the Ganta Hospital.
Within the political tense and dangerous situation, I got almost killed and I left the country for the United States in 2001.
I worked in the Sacred Hospital of Chicago and after a while I completed a master in health care administration.
From 2004 to the end of 2010, I was the public health director in North Carolina.
I asked my father to move out from Liberia and to join me in the United States but he refused.
I was applying for another job in New York as coincidently I focused on the picture of me and my mother lying on the bed and I started crying.
I realised I had not fulfilled my promise.
In search of a new house in New York, I got a call from the president of Liberia, Ellen Johnson, who wanted me to give a speech at the inauguration of a hospital constructed by the Chinese in Tapeta, the 26th July 2010.
It was a brand-new hospital built next to an old one once constructed by the Taiwanese but partly destroyed during the war.
At the occasion of this inauguration, I met the Chinese ambassador and aligned with president Johnson, they both convinced me to take the lead of this hospital.
I could not resist to keep my promise to my mother and to come back to Liberia, although I lost my wife by this.

Due to my expertise in prevention of biological war, I became the medical responsible for Ebola policy and when the epidemic was over, I arrived at this post of chief medical officer."

He didn’t seem to appreciate I shortly interrupted his story as his loyalty to his mother and the fulfilling of his promise had become the mantra of his life which he wanted to share as a kind of universal mission.
“What do you want to achieve in the following years, what’s your dream?” I tried to connect his impressive story to a new challenge for the future
“If you really want to change something in the system, it all starts with leadership and management”, he answered : “My dream is to establish a high end health care management education as a leverage for a better quality of care in Liberia.”
“Maybe we can be partners.” I aligned to his mission.

Dr. Cooper was the Assistant Minister for Curative Care.
She explained that except of the public sector (about 75%) there were a lot of faith-based hospitals and also private for profit institutes in Liberia.
Concerning new initiatives, she referred to the medical imaging centre that was built now in JFK, the plans for radiotherapy, the actual chemotherapy unit in Hope for Women and the nearby establishment of a state of the art unit for breast cancer and cervix cancer in JFK in cooperation with dr. Ann Marie Beddoe.
For specialised training for doctors she referred to the programs of of the Liberian College of Physicians and Surgeons and she admitted that for most highly specialised medical education ,doctors had to be send abroad.

Her lack of Liberian accent and the light brown color of her skin, revealed that she was an American.

Ann Marie Bedoe had had a professional career as a gynaecologist, but she had limited her clinical activity, that means she stopped doing surgery but was still involved in clinical oncology especially for breast and cervix cancer.
She had a special interest for global and woman’s health.
She started to do some voluntary work in the JFK hospital about 10 years ago and recently she was also involved in a project on building health work force funded by the World Bank.
Her support in enhancing quality in breast and cervix cancer was not funded by this project but by her private donation fund.
She came to Libera about every 2 months.

During the last years she took the initiative to train a pharmacist and a nurse in the Mount Sinai hospital in New York, in order to prepare and administer chemotherapy. For diagnosis they worked with FNA, or Fine Needle Aspirations.

At the moment, the unit for gynaecology and maternity had the disposition of an Ugandan pathologist and a second one in the country was linked to the hospital in Tapeta while three other pathologists were in training in Ghana.

In the future they considered tele-consulting for complex case.
Laminar airflow furniture for more or less safe preparation of anti-cancer drugs was available.
The budget for cytostatic drugs was still a problem.

For screening she had proposed a method of visual inspection with acetic acid smears. Screening of APV was ongoing but palliative care was an issue. It was her conviction that first a palliative care unit within the university hospital should be set up with education of nurses and social workers and from that point as a leverage for home care.
In her opinion, conditions were acceptable to start up with the chemotherapy unit in September.

At the occasion of a short visit at the chemotherapy unit in the private facility “Hope for Women”, we met one patient who couldn’t attend the day before and she was alone because treatment was only 3 days a week.

I wondered, based on my experience as hospital manager, how they could provide three nurses for one patient and since the staff was available, why not treating more patients?
The chemo was prescribed in the paper medical file of the patients and apparently nurses mixed the anti-cancer drugs without special precautions.

Dr. Ann Marie Bedoe tried to hide some little skepticism concerning the quality and safety of this ambulatory unit.

She admitted that she had held the pen in the extensive cancer policy letter that was prepared and approved by the cancer committee.
Initially focus would be put on breast and cervix cancer.
Having read it thoroughly, it elicited in me a great respect for the clinical knowledge and strategic vision with “smart” goals in setting up this policy, although I felt quite a substantial gap between the medical / public health language and concepts and the extent to with the NCD-committee would be able to materialise the requirements and implement the program.

Next day we were not welcomed by Adolfos Kenta, the community health department director van Montserrado County.

After a short talk with one of her deputies, a sudden intense teleconferencing indicated that the big boss was considering to join us.
“Mr. Deputy” was banned to the next table and we started our explorative meeting on NCDs, especially cancer.

I stucked a while with the administrative reporting system as we were shown that all relevant administrative and medical information had to be filled in in a prestructured form by the treating doctor or nurse.
Information from these individual files was aggregated in a huge book as a kind of super excel on paper, which was the base for - still written on paper - statistics on number of deliveries and others.

This form was sent to the county where three people did the input in the DHIS2-system, the national medical / administrative database as a kind of datawarehouse that was aimed to guide health care policy on the county level and the national level. Now structured data were gathered on cancer so that screening or early diagnoses mostly depended on the knowledge and attention of the care provider.

Dr. Kenta was not aware of any training for cancer prevention screening, diagnosis of treatment within the last year.
Nevertheless, she pointed out that it was necessary.
Slightly opposing her quite passive attitude, I wondered who was responsible to take initiative to organize certain educations.
Mostly they seemed to be set up and funded by third parties (from abroad) and had to be approved by the county and the Central Ministry.
So there were three “owners” in the triangle who could take initiative …

In our exploration to have an idea of the relevant size of public, private not for profit (confessional) and private for profit health care provision, we got quite substantial different figures regarding the source.
She spoke about fifty public facilities in a total of three hundred.
Only some private centres received money from the government as for example “Hope for Women.”

Her slightly submissive, uncertain attitude towards our inquisitory asking turned triumphantly in a confident clinical authority when I had to beg her for the toilet because of diarrhoea and she provided me with Flagyl to kill the beasts.  

We visited a health centre where a team of five nurses and physician assistants provided consultations without the supervision of a doctor.
Nevertheless, the head nurse seemed to be confident and experienced in doing the job.
I don't know why we had to sign in a kind of guestbook as a written proof of our visit.

Billy C. Johnson was the chief medical officer of the JFK University Hospital.

He had had his education as a gynaecologist obstetrician in in the United States and had worked there for many years.
He corrected my conviction that chemotherapy was not administered in JFK (I thought only planned for the gynaecology tumours in September) as he referred for example to chemo for Burkitt lymfoma with children.
I was surprised that children oncology, which was a high specialized service in some University Hospitals in Belgium, seemed to be a common practice in this hospital.
He requested whether I could mobilize my network to obtain affordable drugs.

Mr. Slewi, member of the NCD unit and responsible for the cancer registry, explained that they were preparing since 2012.
They had collected data on a monthly basis from six facilities since May of this year. The most important source of registration was the pathologist’s diagnosis within the JFK hospital.
They also gathered cancer reporting from other centres without pathological confirmation, but they tried to convince the treating doctor to refer these patients for a pathological confirmation in the JFK.

One of the most burning issues was the unique identification of the patients.
The stigma on cancer was comparable with that of Ebola, although it was not contagious.
Therefore, sometimes people changed their ages deliberately by cheating about their birthdate.
I was also difficult to eliminate doubles: patients who were seeking for different advices in different centres.
By the lack of a national identification number, they asked names, birthdates, addresses and telephone numbers but as mentioned these data were not reliable.

Johnson emphasized on education and awareness of cancer issues: “illiteracy is the biggest problem in this country
At that moment data were collected by a standardized registration form, Slewi showed me, that was filled in by a doctor or mainly by the pathologist.
He showed us his small desk and dusty computer donated by the WHO, where he was putting the data into an excel file, so he could make some statistic overviews.
A special input software from the African Cancer Registry Organization would soon be available but there was no link with the government database DHIS2.
Nicholas De Borman, head of the Belgian software consultancy company Bluesquare, who had already done some work for the PBF unit of Vera Mussah, emphasized that all applications and apps developed for low and middle intercom countries should better be integrated within the DHIS2 system.

During a late lunch in a fancy African restaurant, Vera noticed me that it was forbidden to take pictures of people without their permission.
She didn't notice that I was seduced by the African colours of the paintings on the wall more than the people in the restaurant.

I bought a bottle of ginger beer as an exotic souvenir of Monrovia.

Not respecting the time schedule because of my unsatisfiable curiosity, we missed the appointment with the WHO lady and - I presume the dean of the faculty of medicine had left the spot where we would have met himin my opinion the university building for the students dormitory needed some renovation.

At the Ministry, we had a last reunion to prepare the mission of August.
Embraced by the NCD-team that did a lot of effort to make the mission happen.
Glad being part of this dream team…

Back in the hotel I requested the receptionist to provide me with a confirmation of my room reservation in August.

She did not succeed - due to the failure of the Internet - and despite five reminders from my side, to make a confirmation until just before I left the next day at twelve o'clock, although on paper, because she could not send an email because of the internet that was being shut down.
I did not know whether I should be angry or have pity.

As a perfect host, Vera escorted me to the airport or was there for another half an hour with me to taste the luxury of the Farmington Hotel built by the Chinese.

I posed for her in the garden and at the river and rewarded her with a lunch and a delicious glass of white wine.

Finally, she had fulfilled a Celestine promise for me.

With thanks to :
-the NCD team for preparation and guidance of the visit
-Lonely Planet West Africa
-Lut Brugmans voor de omzetting van klank naar tekst