Liberian Nightmare : In a Ruined Hospital, a Lesson in Aid

Welcome to the John F. Kennedy Memorial Medical Center, Liberia’s showplace health care institution:

-- Patients in the hospital are often infected with malaria two or three times during their hospital stay from the mosquitoes that breed on the swampy ground of this Monrovia suburb. The unscreened windows have to be left open all night because the air conditioning is out of order.

-- An accreditation panel of West African doctors visited here not long ago to discover that not a single toilet in the vast five-story building was operating. The laboratory could not do standard blood or bacteriological tests.

-- The mortality rate of mothers giving birth at JFK--1%--is not only higher than that of the developed world (by about 100-fold), it is five times worse than Liberia’s rate in general.

Grim Twist to Name

“You know what ‘JFK’ stands for, don’t you?” asked one of the professional staff here. “Just For Killing.”

In some ways, JFK is unique among public hospitals in Africa. While space in Kenya’s Jomo Kenyatta Memorial Hospital or Cameroon’s Hopital Centrale is so scarce that patients are deposited two or three to a bed, JFK’s reputation is so bad that there is room to spare. In some wards, fewer than half the beds are occupied.

“I don’t know any Liberian, from my house girl up to Cabinet ministers, for whom JFK is the hospital of preference,” said a Monrovia diplomat.

Yet in many other ways, JFK is a prime example of what is wrong with health care in sub-Saharan Africa. Big-money, high-tech institutions like JFK, built by Western donors and filled with equipment that their host countries cannot afford to operate or maintain, have drained money from programs that most experts in Third World health say are really needed: primary health care.

Basic Help Needed

That means simply that people in the countryside who cannot be reached by doctors and sophisticated equipment must at least be well nourished, provided with clean drinking water, and shielded from infection and common parasites. With these basics, professionals say, most measures of general health would improve in many Third World countries faster than with any number of central hospitals.

But until recently, Western donors were bent on financing grandiose medical centers in African capitals, modeling them after the technically advanced institutions that went up in the 1960s and 1970s at home.

This, in turn, reinforced the African recipients’ conviction that grandeur in public works by itself creates efficiency and growth--the notion that has given Africa so many suspension bridges to nowhere, hydroelectric plants serving uninhabited quarters and, indeed, modern hospitals without nurses, doctors or patients.

Yet the builders of these projects ignored the signs that equipping developing countries with complicated foreign equipment was a guarantee that it would go unused.

“The health care system in any developing country is a bottomless pit,” observed Nigerian Health Minister Olikoye Ransome-Kuti recently to a group of African health administrators. “You have to keep topping it off because nothing is produced locally.”

Staff Often Poorly Paid

As at JFK, staff at African hospitals are commonly paid impossibly low wages and foreign donations are more easily secured for equipment than for training. It is common at Kenyatta Memorial for staff physicians to demand payoffs before seeing public patients on the hospital grounds. An immense new hospital at Youpougon, Ivory Coast, on the outskirts of the capital of Abidjan, remains an empty shell in an unlandscaped field because the country cannot afford to staff it.

Elsewhere, Western standards of medical practice are still woefully unfamiliar. American researchers not long ago determined that Mama Yemo Hospital, the public institution of Kinshasa, Zaire, had created as many as 90% of the city’s pediatric AIDS cases in 1985-86 by treating child malaria with transfusions of poorly screened and contaminated blood. The U.S. consultants ordered the staff to cease the largely unnecessary malaria therapy, and child AIDS cases dropped sharply.

In Liberia, JFK’s deplorable condition has been a byword for so long that perhaps the most surprising thing about it is that people have recently been getting stirred up about it. A “Save JFK” fund drive has been launched, complete with musical appeals on state radio and television. President Samuel K. Doe was moved to conduct a surprise tour of JFK’s maternity unit, which was renovated just two years ago with Japanese money and rechristened the Liberian-Japanese Friendship Center.

The U.S. government funded JFK with a $6.8-million construction loan in 1965, building the main hospital, the maternity center next door, and the Tubman National Institute of Medical Arts, the medical school and training center for nurses, paramedics, and midwives. The Americans added another $10 million in grants through 1978 to finance the U.S.-based training of technicians and to pay for supplies.

After that, the Americans phased out their participation. As foreign aid dollars shifted to primary health care, JFK quickly began to slide. Its Japanese and American machinery could not be maintained without sending abroad for spare parts--and sometimes for repairmen too. Given Liberia’s chronic shortage of foreign currency, orders could not be placed.

“All the X-ray machines come from Japan so there are no maintenance men here who know how to repair them,” said Dr. Patricia Divine, the Liberian physician in charge of JFK’s maternity unit. “Almost all the air conditioners in the rooms facing the ocean are broken, and they can’t be fixed either.”

It was Divine who provoked the latest spurt of attention paid to JFK, by writing a newspaper article entitled “JFK Medical Center--A National Tragedy.”

In it, Divine assailed the overpopulated and incompetent staff, charged the politically appointed board of trustees with inaction, and asked: Why, if money is so scarce that the center cannot buy drugs or supplies, did Dr. Walter Brumskine, the hospital administrator, borrow $62,000 in hospital funds to buy himself a Mercedes-Benz?

(Brumskine, who maintains a thriving private practice as Liberia’s only urologist, later said that the loan came from a government pool available to all top-level civil servants.)

Interviewed in her cramped office where she shares a couch with piles of dusty records and reports, Divine expresses surprise at the reaction to her article, which ran twice this summer at full double-page length in Monrovia’s Daily Observer.

“My friends asked me why I bothered because nothing would come of it,” she says. “But the hospital was just going downhill.”

No Mops for Janitors

It is not surprising that what was once a genuinely modern and well-equipped facility should now be viewed by Liberians with contempt and even fear. A visit to JFK is a tour of dim, cheerless corridors occupied by idle staff and hangers-on. Its legions of janitors are unequipped with mops or wringers, so garbage and dust is swept into mounds and left in the middle of the hall.

Its security guards rarely question intruders; they cannot seem to keep drugs from disappearing from the dispensaries or equipment ranging from blood-pressure gauges to laboratory scales from being walked out the door.

Although medicine and surgical supplies are supposed to be free, patients are often handed lists of what they will need for their operations, including sutures and intravenous drips, and told to go buy them. The supplies are so expensive that many patients set off on these buying expeditions and never come back.

Power outages and mechanical failures are a daily occurrence. The center’s morgue has been announcing over state radio that it can accept no more “dead-on-arrival” bodies until relatives come to claim the ones that are already lying around decomposing in the absence of an operating refrigeration system.

There has not been an autopsy performed at JFK since 1983. “That means,” said a physician, “that we can’t even learn from our mistakes.”

Running the place is a man whom even sympathetic observers characterize as an ineffectual administrator stuck with an impossible job. Brumskine is a man with a beleaguered manner whose first initiative on taking over in 1985 was a disaster: He chose a presidential election year to propose firing 30% of the largely patronage-protected staff of 2,000.

“My layoff plan was a political blunder,” he conceded in an interview. He has not raised the issue since then; today his own office is staffed with no fewer than four secretaries idling the day away.

Brumskine blames JFK’s condition on the government, which rarely provides the hospital with the foreign currency needed to buy supplies, spare parts, and drugs.

“Considering the type of financial difficulties we have, I don’t think that we are doing badly,” he says. “It’s a wonder that the whole system hasn’t completely fallen apart.”

But if JFK is a place that has not “completely fallen apart,” it is hard to visualize what is. Attending physicians, who all maintain private practices but are theoretically bound to remain at JFK from 8 a.m. to 4 p.m., are almost never around. Those who do report often refuse to see public patients or else charge them illicit fees for treatment supposed to be done at the nominal JFK rate.

Residents “may or may not turn up for assigned duty or for call,” says one European physician at the hospital. “Their schedules are not approved by anybody. But there’s no discipline administered because then you might lose them altogether.”

The pediatrics ward was long ago robbed of all its thermometers and blood-pressure meters. One doctor, who asked to remain unidentified by name, said he was recently told by technicians that they could not perform an X-ray because the department was out of film. When he asked the radiology supervisor about it, he was told, “Oh, there’s film, but they deny it because they don’t want to work.”

Small, Large Babies Die

In the pediatrics and maternity wards, where charts are written on whatever scraps of paper the doctors can scrounge, the death toll includes potentially healthy children as well as sick ones. Many babies are premature, weighing less than two pounds because of their mothers’ poor health; few of those survive. But attending doctors qualified to perform Cesarean sections are so seldom around that oversized babies who can’t be delivered conventionally also perish in birth.

“So we lose the little ones who are premature,” says one doctor, “and we lose the big ones we should be able to help.”

Patients, who are charged a nominal service fee, run a separate battle with JFK. Divine says she has seen patients treated free after pleading indigence, only to display thick bankrolls to ward mates, “triumphant at having duped the system.”

The pediatric wards are filled with children abandoned by parents fighting the hospital over their JFK bill.

“When the time comes to check out, the parents might not have the $35 to pay the bill,” says one doctor. “So the child stays for three or four months getting fed as the bill mounts up at $5 a day, until someone just gives up. The child is either discharged, or an ‘auntie’ comes in the middle of the night and takes him away.”

JFK’s problems might seem beyond repair. Certainly they did to President Doe, who emerged from his recent visit squinting in the bright sunlight wearing a blue surgical gown and his characteristic befuddled look after viewing the vacant pharmacy shelves and filthy corridors .

“There’s no medicine, no drugs,” he reported. “At the moment we opened the hospital everything was here. Now, things are out of control.”

Yet Doe’s government has treated JFK like any other public institution: as a patronage mill. Most of its 2,000 workers are superfluous clerical and maintenance staff. Their salaries totaled $6 million last year, or 80% of the center’s total budget of $7.5 million. The politically sensitive salary bill is actually the only part of the budget that the government makes an effort to pay. Of the $1.5-million non-personnel budget approved for JFK for this year, Brumskine says, only $150,000 had been received from the government by midyear.

Pay Slow in Coming

Even so, like most civil servants in Liberia, the JFK workers are consistently owed two to three months’ back pay. That contributes to the difficulty of motivating them to do anything.

This is not to say that any individual’s pay is princely. A senior staff physician makes the equivalent of $450 a month, a registered nurse $175.

“It’s chicken feed,” acknowledges Brumskine.

Not surprisingly, 30 doctors quit the staff last year; since 1984, at least 45 nurses, more than 10% of the hospital’s complement, have also left, partially in response to an American program inviting foreign nurses to emigrate after they pass a competence exam at the local U.S. Embassy.

Whatever money comes in flows back out with a typically Liberian perversity. Over 18 months in 1987-88, according to one financial report, the center spent $511,000 on drugs and X-ray and lab supplies, and fully $1.07 million on telephone calls. About $100,000 was spent on new Volkswagens for deputy administrators, on the grounds that they needed transportation to go home for meals because the hospital food was so bad.

Few people here have any hope that the recent furor will inspire the government to improve JFK’s condition.

“Political will here waxes and wanes,” says a Western development official.

Others point to the failure of the government’s strongest initiative ever at JFK: shutting it down entirely in 1984 for what was billed as a major renovation. When it reopened a year later under the newly appointed Brumskine, experienced people were mystified to find the “new” JFK looking exactly like the old one.

“It was not very clear to me,” Brumskine says, “what went on during that renovation.”

Characteristically, Liberia’s momentary interest in JFK has already begun to evaporate. The “Save JFK” fund drive quickly took a back seat to competing drives, particularly a public raffle to finance the World Cup aspirations of the national soccer team, the Lone Star. A day after his JFK tour, President Doe publicly kicked off the Lone Star campaign by personally donating a new four-door Volkswagen sedan as the grand prize.

“JFK has gone back on the back burner,” remarked one development official. “The trouble is, in this country the front burner is a mile long.”