This article was originally published by Ebola Deeply.
By Kate Thomas
James Kaikai is the administrator of James N. Davis Jr. Hospital in Paynesville, Liberia – an 80-bed hospital that serves a catchment area of 250,000. He sat down with Ebola Deeply to talk about oxygen shortages, generator fuel and other health system gaps in the wake of Liberia’s Ebola outbreak.
The health facility, known locally as JDJ Hospital, was donated to Liberia by Médecins sans Frontières (MSF) in 2010, after serving as an MSF health facility following Liberia’s 14-year conflict. It’s now financed and run by the Ministry of Health, in conjunction with partners including Mercy Liberia. Although the hospital has an emergency department, it largely operates as a pediatric and OB-GYN health facility. It also has a forensic lab that processes samples used to help prosecute perpetrators of sexual and gender-based violence. Technicians and doctors from the hospital have, in the past, provided testimonies from patients to be used by Liberia’s Ministry of Justice in court. All care is free, although some forms of medication must be purchased on prescription.
Ebola Deeply: How was the situation before Ebola at JDJ Hospital, and how has it changed since?
Kaikai: During the period of Ebola, through the grace of God, we were not hit directly. We had a case with one of our staff who died from Ebola outside the hospital, but we never had a case inside the hospital. However, we lost 20 to 30 percent of our staff when they went to work in Ebola treatment units (ETUs). When international organizations came to help Liberia fight the outbreak, they recruited those staff to Ebola treatment units that they had explicit confidence in; staff that had the expertise. So that posed a challenge for us during the Ebola outbreak.
Normally per shift, before Ebola, you had anywhere between 40 and 50 staff across all sectors of the hospital; not just the clinicians, but the cleaners, the lab staff, the laundry people … you had the cooks who provide food for the patients, you had the nurse aides who assisted the nurses on the ward, you had the nurses themselves, you had the midwives, you had the physicians’ assistants, and you had the doctors. You had the staff who assisted in sterilizing. There was a wide range of them.
During Ebola, staff numbers reduced drastically. In fact, there were certain subsections that were not functioning, like in Ebola time we were not doing no surgery. You had less of the physicians’ assistants; I think we had an average of two. Doctors were few because they were needed to fight in other ETUs, and some traveled. You had basically a commitment from the support staff. The ward security staff were here but not much patients to watch. The cooks were here but not much patients to cook for. At a certain point I had to motivate my staff because of the low number of patients that was coming. In fact, we encouraged staff to come by providing meals. You know, many people did not want to openly go out fetching for food because of the disease. They were afraid to have contact. So most people were staying in. So we offered meals, and staff started coming back to work. That’s how we picked up.
Ebola Deeply: What other challenges did you face during that time?
Kaikai: We had not only the challenge of staffing, but we also had an issue with the patients. Because of the fact that health workers were coming down with Ebola, people had their own negative perception that when you go to the hospital, you’re going to come down with Ebola. Many men told their pregnant wives not to come. So there was an issue with people not getting the care they needed.
We strategized and even went ahead to organize an ambulance system in the communities. Teams of medical staff and psychosocial staff went into communities and identified sick people. If someone was displaying the signs and symptoms of Ebola, they wouldn’t bring them to this hospital; we were here handling non-Ebola patients. We had to go out and look for non-Ebola patients because we were worried they weren’t getting care. This is how we were able to manage. It took close to four to five months for patients to come back to the hospital after the worst of the Ebola outbreak. We did a lot of community outreach, especially with community leaders, to regain that confidence, to say, “The hospital is there for you, and you can come.”
And we also encouraged our health workers who were making fabulous salaries in the ETUs, to remember that they have brothers and sisters who are not just Ebola patients. There were people dying who were not Ebola patients. They needed to divert their attention somewhere in between. Some of them said, “Let me leave money, and come and help.” We were grateful to them. There were many who made the sacrifice like me. I had the opportunity to go to ETUs for a job but I turned them down. Leaving the hospital would have meant letting it collapse. The medical director was not here; she was in America when the outbreak started. I had to beg, beg, beg her til’ she came back.
Ebola Deeply: Did you have any support from the government or other additional partners?
Kaikai: The government focus at the time was on the ETUs. Logistics for the Ebola fight were limited for those who were handling basic health services. We want to give special thanks and appreciation to MSF Belgium. We also had tremendous, tremendous support from the African Union. They came in and provided manpower. It ranged from doctors down to even aides and nurses. They were very helpful to us. Even when they were leaving, it was tears in the eyes for everyone.
Not only that, they also gave us a state-of-the-art operating theater. They did a renovation of our theater that is a state of art. Very beautiful. You can feel comfortable doing surgery, unlike what it was before. Even our surgical beds – they brought new surgical beds! The ones we had got corroded from the chlorine. They didn’t stop there. They went to our OB ward and they revamped it, and gave us a very modern delivery room. So we’re very grateful to the African Union. That was a high level of African solidarity. They never just came with their money, but they also provided manpower, and they risked their own lives to ensure that the hospital could remain open. There was a lot that we learned together, and we can continue to go on and on and on … but it was a beautiful experience. Their health delivery was splendid. We were all new to Ebola; it was not a special case that we learned in school.
Ebola Deeply: What are the greatest health gaps at the facility now? What do you worry about?
Kaikai: We’ve been singing the oxygen song since last week. On Friday evening, we had three bottles. Saturday, one was gone. Sunday, another. Now we have one left. Liberia has only one major oxygen factory – owned by the Chinese – and every hospital here relies on it. There’s a huge demand. At times the supply is limited, you always have a rush. If, here at the hospital, we had a large supply of oxygen concentrate, we could save lives. Normally we consume ten bottles of oxygen on a weekly basis.
Each bottle costs $35. We spend at least $250 every week on oxygen. If we could have more oxygen concentrate, that would reduce our costs as well. Right now, we only have one oxygen concentrate, but there’s a case that requires surgery. We have to remove that from the emergency room and take it to the theater for it to be ready. And there’s a need for the current to be on; city power is just not reliable enough to do surgery.
The electricity generator needs to be on. And we need fuel. Right now, just before you came here, I gave instructions: Let it be on with the fuel, so that the surgery can be conducted. Nevertheless, we’re working with it, and we’re trying to ensure that we save lives. That’s our priority. But if we could be beefed up in our budget allotment, trust me, we have the expertise that can deliver. Other hospitals are in a position where they have a bigger budgetary allocation. We only receive about $100,000 from the government each year. It’s very little. So we also rely on our partners for help.
Ebola Deeply: What’s your vision for the hospital in the coming years? What needs to happen?
Kaikai: My hope for the future is to see the hospital second to none. One, to have a more larger space. Two, to increase our services, not limited to just pediatric and OB-GYN cases. Right now, if we can expand into a broader space, we can be in a position to not just limit the hospital to children and women. We want to allow men to have the opportunity to come and be attended to. Right now, if a man comes, we can do surgery on him, but where will we admit him? There’s no ward for men. These are things that we want to see. We hope and pray that we will be able to increase services to the people.
The cost of living right now is extremely high. As a result you find health workers taking two jobs. If you can be adequately paid to do a specific duty, you will put in your all. So salaries need to go up. A doctor here receives between $800 and $1,500 a month. You have nurses that are receiving $80 to $100 a month, maybe a little more. It’s very little. Even as an administrator, if I tell you my salary, you will say, “Wow!”
Ebola Deeply: Has Ebola taught you anything?
Kaikai: As painful as the process of Ebola was, also it has its positive side. The negative side was that it cut out lives. But it has exposed the weaknesses of the health sector. This has given us, as hospital managers, a broader perspective as to how we can improve our system.
One of the basic things is that there should be priority when it comes to health. When you’re healthy, you can concentrate. You can do things. If you’re not well, you cannot do much. So health should be a priority. The government needs to put in more support and solicit more assistance. Take for example our hospital; it’s surrounded by neighborhoods. We’re talking about expanding the hospital. The government should be in a position to talk to these people and compensate them. There’s a need for more capacity building. They need to look at it as I see it.
We’re talking, they’re listening. But the government has their own constraints when it comes to money. They’re going to respond based on the available resources. Right now, our major, major, major natural resources are being used for revenue generation. Let the government focus on health, because health is the key. If you’re healthy, you can sit in the classroom. If you have a sound mind, you can sit in the classroom. Health must come first. Education comes later.
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Kate Thomas is a British-American journalist, editor and researcher who lived in West Africa for seven years. Her research interests include the relationship between health and narrative, as well as African migration.
[Photos courtesy of Ebola Deeply]