Summer 2023 Travel Journal

Mike’s Liberia Journal

June 19, 2023

I recently returned to Liberia and am excited to write my first journal in two years. Shortly after my last journal, a devastating wave of COVID-19 hit Liberia and I was urgently called back to Liberia to aid their government. I could not really talk about a lot of what I was doing during that time, and then fell out of habit of journals. But, thank you all so much for your care and support in these years, and I can summarize most of the gap in this prologue to my current trip!

Third Wave of COVID-19 in Liberia –

About two weeks after my May 2021 trip to Liberia, I received a call from the Minister of Health of Liberia. COVID-19 had spiked in a huge way since I had left and the COVID-19 Treatment Units (CTUs) were overwhelmed. More concerning, the mortality rates were through the roof (greater than 80% for folks requiring oxygen the week that I arrived). She asked me to come serve as her consultant for the national COVID-19 response and sent a letter requesting my assistance to my boss and also my department Chair at Indiana University. They fully supported this and within a few days I was on a one-way flight to Liberia. I spent several months in Liberia in daily meetings with the Incident Management System (IMS) which is their sort of “national catastrophe management group”. It was founded during the Ebola epidemic and had been dormant since then. It consists of the Ministry of Health, the CEO of JFK Hospital (the national hospital), some other members of Cabinet, the regional heads of the CDC/WHO/USAID, the National Public Health Institute of Liberia, and various other high-level folks.

An IMS team member working in the National CTU during the Third Wave.

I ended up recommending a three-tiered plan for handing the Wave. Immediately, we needed to optimize oxygen delivery at the CTUs and minimize waste. This would both improve outcomes of those current patients receiving oxygen and also allow us to treat more patients by conserving oxygen (the CTU stayed at 100% capacity even as we increased the available oxygen, meaning there was really a line out of the door of critically ill patients). This could also be done within a matter of weeks. Second, we needed to scale up training for managing patients with COVID-19 for healthcare providers to increase the workforce able to effectively work at the CTUs. This would allow us to open and staff more facilities and therefore treat more patients. This could potentially be done in a couple of months. Finally, we needed to increase the production of oxygen in Liberia quickly by installing oxygen generation plants. This, at best, would take six months.

My recommendations were accepted by the IMS and we went to work. We had updated the treatment protocol at the CTUs within two weeks, which was great because outpatient numbers were not decreasing. Just a few changes allowed us to treat about 25% more patients with the same oxygen capacity. Clinton Health Access Initiative (CHAI) generously offered to fund and staff urgent trainings for treating patients with COVID-19 in every county in Liberia. Thanks to CHAI’s amazing efforts, healthcare workers from all 15 counties were able to be trained (in part by our respiratory therapist (RT) graduates from the Liberian Respiratory Care Institute (LRCI)!) and complete competencies on COVID-19 treatment protocols within 60 days. Our co-founder, Scott Dwyer, even flew over to help with those trainings as well. Shortly thereafter, I was notified that USAID approved one million USD to urgently install oxygen generation facilities in Liberia. Fortunately, around this time the incidence of COVID-19 had started to decline. Within 3 months, the “Third Wave” was ending and I was able to head home feeling that Liberia was in much better shape for whenever the “Fourth Wave” would arrive.

Attendees practice respiratory assessment on one another in the second multi-county COVID-19 training

session.

Partner Liberia assisting the MOH and CHAI with training local medical professionals in the application and administration of oxygen to help improve COVID-19 outcomes

Liberia Respiratory Care Institute –

The LRCI is still going strong. We saw an uptick in enrollment after the Third Wave, due in large part to the role of our RTs at the CTUs and in the nationwide trainings. We have graduated another two RTs in the past two years who have entered the workforce and have fourteen students currently enrolled. We have moved our campus to another site that is more conveniently located due to reasons listed in the next heading.

The CHAI COVID-19 training team and a multi-county cohort of students (and me).

Oniyama Specialist Health Center –

Unfortunately, a casualty of COVID-19 was the Specialty Health Center. It might seem counterintuitive that a respiratory specialty center would not thrive during a respiratory pandemic, but, that was the case. This health center is located within a mile of the main CTU. During the pandemic, all suspected cases had to go to the CTU for screening before they could receive treatment anywhere else. We were unable to become a CTU, and instead sat mostly empty after the Third Wave. After meeting with our partners and the Ministry of Health, we decided it just was not sustainable in its current location (especially with the CTU being able to serve the same community as our Center after the Third Wave passed). We have since moved to another campus in another underserved area on the outskirts of Monrovia where we maintain a respiratory clinic and house the LRCI. We are still able to treat respiratory patients here and it serves as a clinical training site for our students. More on that in the journals from this trip.

I think that pretty much sums up the gap. My focus for this trip is on three projects: 1. Checking in on the LRCI and seeing what is needed there; 2. Establishing a pediatric respiratory treatment program at JFK hospital with some of my partners from Indiana University; and 3. I have been invited to help establish a PhD program in Biomedical Science at the University of Liberia. I will be in country for three weeks, hopefully able to devote a week to each of these projects.

Thank you so much for your encouragement and support in this work--your generous gifts help make all of this happen!  As always, feel free to share these journals with anyone you think will enjoy this. This posting is available on our social media and website (www.partnerliberia.org).

Thanks,

Mike

Spring 2021 Travel Journal

Mike’s Liberia Journal

June 5th, 2021

This trip to Liberia is my shortest (and most focused) to date. Twelve days (minus a few hours), able to be summarized in a single journal! We needed to upgrade the laboratory and operating rooms, so a huge purpose of the trip was me delivering supplies.  I landed very late on a Monday night with 320 pounds of luggage.

Yup, 320 pounds. Of that 320, approximately 30 are for me.  Then there are 100 pounds of surgical equipment, 150 pounds of laboratory equipment/supplies, and 40 pounds of random hospital supplies.  It is a lot to handle while trying to navigate an airport alone. Luckily, I found the only skycap working at pandemic-times Dulles as soon as I arrived.

Our laboratory needed an upgrade – our new hematology system we installed last trip is going so well we already need more supplies and to update the unit itself. Same with our chemistry device. While the logistics of getting the supplies there are suboptimal, it’s a “good problem” to have. Especially while flights are so cheap that it is much cheaper and easier to fly them there personally than to ship.  And it justifies me coming back to Liberia, which is always fun.  This equipment would otherwise have cost several thousand dollars to ship securely and would likely have taken weeks to arrive.

I started off the trip on a fairly unpleasant note. I had been warned that hassles at the airport (and roadstop checkpoints…and just about everywhere) were extraordinarily prevalent…and that proved to be true. After two hours of hassling over extra “fees” and “duties”, I finally got out of the airport with all of my belongings and those of the hospital. After 30 hours of travel, those last two hours were even more frustrating than usual. Luckily, my ride was there with some friends to help with the luggage; I was in bed within an hour of leaving the airport. 

First project, updating the hematology device:

 As I mentioned in the last trip, the hematology machine we use is quite novel. The Olo™ machine is made by Sight DX and is, in theory, ideal for the Liberian healthcare environment. It requires no reagents, its kits do not require refrigeration, and its results (and any errors) can be accessed remotely from anywhere in the world. It is really, really cool.

Sight DX was eager to partner with us as a “trial run” of their device in this environment. This is the first Olo™ on the continent and, due to its austere conditions, Liberia is a great test site. This trip, they have provided us with a new Olo™ to swap out with the one we installed in February; I will bring back the old one for them to evaluate for effects from a few months of life in Liberia.

Along with swapping out the device, I delivered 450 new test kits, which should last until my next trip over (September). If we keep increasing our services, they may not (another “good problem”)…in which case, Sight DX has pledged to find a way to get more here in the interim.

Our lab staff, Ibrahim and Theo, were thrilled to get the new wonder-tool. We managed to have it fully installed and working within one week of arriving in country.

Once I had the Olo™ up and running, I started the process of unpacking, sorting, and inventorying our new surgical tools.

This was a huge donation from our friends at Brother’s Brother Foundation (BBF). We have worked together for almost a decade on healthcare and solar power projects. A few years ago, they donated all of our hospital exam tables and enough medical monitors and other equipment to fill a shipping container. Our hospital would not be open without their generosity.

Last year, a surgeon starting performing small surgical procedures at our hospital. He made a shopping list of surgical tools he needed that he could not find in country. I turned the list over to BBF and they responded with 100 pounds of very high quality surgical tools: multiple copies of everything on the list, jam-packed into three surgical trays to minimize space since they knew I had to carry it all over. After a few hours of unpacking and inventorying, we have a very well-stocked operating theater.

After setting up the laboratory and OR, I spent the rest of the trip treating patients and expanding our respiratory care unit at the hospital. We were fortunate to receive a donation to double our oxygen capacity at the hospital and also to have a few of our broken oxygen concentrators (previously donated by BBF) serviced by a biomedical engineer training seminar. This was perfect timing as COVID-19 numbers were (and still are) rapidly increasing in Liberia.

Liberia largely dodged the COVID-19 pandemic of 2020. In March of 2020, when the first COVID-19 patients were noticed in Liberia, the government closed the borders. No airlines, no land crossings, nothing. Schools were closed, mask mandates were put in place. Expats in the country were offered chartered flights from the Embassy every few weeks to get home. The country really shut down from March until the end of July. Although they had a small wave of COVID-19 in the Spring, it did not overwhelm the system.

When the borders reopened, the rest of the world had stopped travelling so there wasn’t much of an opportunity for COVID-19 to come into Liberia. They also had implemented testing requirements to enter the country. Even when I came back in February, the flights were pretty empty and the government was being quite serious about testing upon arrival. But, by March, the world had started travelling more frequently. Most international agencies in Liberia had brought their staff back, “necessary” business travel had resumed, general activity was increasing. However, vaccination rates in Liberia remain quite low and very little of the population have been exposed to COVID-19. Liberia is quite vulnerable to this pandemic that has already beaten upon so many other countries. Combining increased international travel with the onset of rainy season for the Summer (during which people tend to congregate indoors) could cause a significant uptick in COVID-19 infections. In preparation of this, we increased our capacity in our respiratory care unit at the hospital. Luckily, the largest oxygen plant in the country is only a few miles from our facility.

Unfortunately, there was a significant spike in COVID-19-positive cases arriving at the airport in the days before I left (108 new cases on the 6 flights before mine, and “many” that exited the plane on which I departed the country). I flew out on Friday and the Minister of Health called us on Monday to ask for our facility to serve as the overflow site for the national COVID-19 treatment center as it was becoming overwhelmed. I’m glad we prepared for this, but, I’m very concerned about what the next few months in Liberia will look like. I’m currently scheduled to go back in September but may go sooner (and bring some colleagues) if the pandemic gets too bad there. In the meantime, I will hope not. 

Winter 2021 Travel Journal #2

Mike’s Liberia Journal

Feb 20, 2021

Week two started off with a bang. Sunday morning, a press release came out declaring an outbreak of Ebola on the Guinea/Liberia border. This is the same place it started last time, a four hour drive from us in Monrovia. This was obviously bad news. We increased precautions at our hospital, moved triage outside, and hoped for the best. By Wednesday, suspected cases had made it to Monrovia.

As happened last time, once Ebola is around and in healthcare facilities, people are afraid to seek care at those facilities and travel elsewhere. This makes sense…I wouldn’t want to get treated at an Ebola hotspot, either. But this causes the disease to rapidly spread outside of the initial outbreak since some of these travelers are unknowingly sick with Ebola. The 2014 Ebola outbreak actually started in December of 2013 and was in Liberia as early as March of 2014, but the numbers stayed very low until June. They were all in the bush – rural areas in the region that share borders with Guinea, Sierra Leone, and Liberia. In June 2014, a woman in Sierra Leone fell ill and got in a taxi headed to Monrovia. The epidemic was much worse in Sierra Leone and Guinea at that point, so she headed away. She arrived at the facility where I was working, and within two weeks Ebola was running rampant in Monrovia. 

This time, the patient was from Guinea. She arrived to a clinic in Monrovia with symptoms of Ebola. She and her contacts were immediately isolated, treated for symptoms, and tested for Ebola. Test results are pending, but we are all certainly on high alert. Luckily, Liberians are familiar with and appropriately terrified of Ebola. Locking things down was much easier this time. 

On Monday, we started our main hospital project of the trip – upgrading the lab. 

Quality laboratory testing capabilities are lacking throughout Liberia. When we opened the hospital, we decided two of our main foci for areas of excellence to have the greatest impact on healthcare for Liberians would be respiratory care and laboratory services. Respiratory care was easy; it is what we’ve been doing for years, we have the workforce and the training college. The lab has been trickier. Supply chain in Liberia is tough; even if you can find laboratory equipment in country or bring it over, you may not be able to maintain it. Most laboratory machines require proprietary calibration fluids and testing reagents that are not readily available in country. Even when they are available, they tend to have short expiration lives and require strict storage conditions (refrigeration, darkness, etc). Most healthcare centers in Liberia have a tomb of laboratory equipment that is fully functional, just not serviceable. Indeed, we inherited laboratory equipment worth several hundred thousand dollars from an Ebola research group that we cannot use for these reasons. 

We have approached this problem from two angles: quality manual tests and sustainable technology. Many of the most important lab tests can be done manually by a well-trained laboratory technician. Things like malaria testing, hematology, and urinalysis, for example, can be done with a microscope and some basic stains, so we hired Ibrahim, an expert who trained in Liberia and is used to doing manual tests. Manual tests have limitations, however – more complex testing cannot be done manually, and the tests that can be done manually tend to take a long time. For instance, a manual hematology assessment takes approximately an hour. This is not feasible in a busy center like ours, so we needed sustainable technology options. 

The first device we brought over was an iStat®. An iStat® is a pretty amazing gadget. It came out about twenty years ago and it still unparalleled on the market. It is about the size of a 1980s cell phone, battery powered, and can run full chemistry/metabolic/respiratory panels on a few drops of blood in under three minutes. Even better, it requires zero reagents. It requires a small chip for each sample, similar to a glucometer for diabetes. These chips aren’t a perfect solution – we have to buy them (not cheap), get them to Liberia, and they only have a few months of shelf-life. But, once we have them in country, they are pretty robust. Also, the test process is extremely user friendly; Ibrahim can train just about anyone to run them while he focuses on more complex procedures. So, the iStat® is pretty great. I brought over several hundred chips this trip that should cover us until my next trip and updated the iStat®, so we should have a functional chemistry/metabolic/respiratory lab unlike any other in the country for at least four months. Unfortunately, the iStat® cannot do hematology panels.

This trip, we brought over something really exciting. Scott found a device called the Olo®. This is a “dry” hematology machine. It’s roughly the size of a shoebox, requires no reagents, and, similar to the iStat®, just needs a chip and a few drops of blood to do a full hematology panel. Even better than the iStat®, no updates are needed and the chips have a 13 month shelf-life. The device may also be used to detect malaria, sickle cell, and other blood disorders. This technology is brand new; in fact, this is the first unit on the African continent. The company, Sight Diagnostics, is quite excited to see how it performs and has been incredibly helpful (and generous). Instead of a manual hematology panel requiring an hour of Ibrahim’s undivided attention, this chip takes about a minute to load and the machine spits out the results in ten minutes. 

By the end of the week, we had a fully functional, state-of-the-art laboratory at our hospital.  

Winter 2021 Travel Journal #1

Mike’s Liberia Journal

Feb 13, 2021

After a full year of being out of Liberia, Scott and I returned last Friday. This is the longest we’ve been out of Liberia since I started working here in January of 2010. Being such a challenging year in the rest of the world, I feared that Liberia would feel different, that I would have catching up to do. Oddly enough, Liberia has managed to stay largely unaffected by Western politics and the COVID-19 pandemic.

This was my first international travel since COVID-19 and I expected many changes. Liberia mandated negative COVID-19 PCR test results that were obtained within 96 hours of arrival to Liberia, meaning we had to have the swab done no earlier than Monday night and had to have results before we left the States. This is trickier than it sounds, particularly for Scott who was coming from Oregon.

Normally it takes around 24 hours to get from the US to Liberia. Due to COVID-19, there are less flights and much longer layovers. Scott had to fly from Portland to Denver and Denver to DC (I just flew from Indianapolis to DC). Then we flew from DC to Brussels, where the normal 4 hour layover has become 8 hours long. Then 9 hours from Brussels to Freetown and another 2 from Freetown to Monrovia. For me, this was 30 hours of travel; for Scott, it was almost 40. This left a two day window to find a PCR test AND get results. We both managed to get them but it was quite a challenge (most rapid tests are not PCR).

The airplane experience was fairly similar to that before COVID-19, but with masks. Brussels airport was a ghost town, with one bar/coffee shop open in the entire airport. At least we had each other’s company, otherwise it would have been an amazingly boring 8 hours. After almost two days of travel, five airplanes, and a few small hassles at the airport about our testing, we made it to Liberia. We checked into the airport hotel and promptly passed out.

Our first morning was met with a great surprise. While having our breakfast, I heard someone shout my name from across the hotel yard. It was my friend Jenny carrying Mary Beauty. Mary Beauty is a three month old chimpanzee!

Jenny and Jim founded and run Liberia Chimpanzee Rescue and Protection (LCRP). Liberia has one of the largest remaining groups of chimpanzees in the wild and they are still targets of poachers for bush meat. When hunting chimpanzees, mothers are an easy target as they are weighed down by the baby chimps they are protecting. Poachers kill the mother for meat, then collect the babies to sell as pets (to ultimately grow big enough to be eaten).  Orphaned baby chimps cannot live on their own in the wild, so, the only real option for them here before Jim and Jenny arrived was death or the pet trade.

LCRP works closely with the Liberian government and communities to prevent hunting and protect the chimps in the wild. They have been hugely successful; when I started coming to Liberia, bushmeat and live endangered animals were at major intersections for sale daily in Monrovia. Within a year of Jim and Jenny coming here, that vanished. However, hunting and bushmeat/pet trading continue to happen, just less frequently and more underground. When someone is caught with a baby chimp, the chimp needs somewhere to go. LCRP has built an incredible sanctuary that now houses over 60 chimps between infancy and adolescence. It isn’t as great as if they were in the wild, but it is pretty wonderful. And hard work…Jim and Jenny have over 60 wild and rambunctious kids, effectively.

Like humans, chimps get sick. Respiratory illness remains a leading cause of death in humans in Liberia and is the same for chimps. The only three chimps they have lost since opening LRCP have died due to respiratory illnesses, including the one I helped bring to them in 2017. When the chimps get sick, I consult on respiratory treatments options. This trip, I was able to secure some respiratory therapy equipment and medications to have on hand for the next time (special thanks to our friends at Tender Hearts Home Health Care for the equipment!). Sure enough, right after we arrived LRCP received a new baby chimp with a respiratory infection. After treatment with the nebulizer and drugs we brought, this chimp (named Scout) is stable and moving in the right direction. It is a great way to start the trip.

We headed to town after meeting with Jim and Jenny (and Mary Beauty). On our way in, I was struck by how much hadn’t changed. It really is like Liberia has been spared of the pandemic. For the first time since March, I felt like I was in a place that somehow dodged 2020.

Liberia is no stranger to pandemics. Even though it has been five years since Ebola, it is still fresh in everyone’s mind here. When COVID-19 started, Liberia took it seriously. They completely closed the borders in mid-March and kept them closed until the end of July. The economy suffered, but, they effectively dodged the pandemic. They had a small surge (a few hundred cases) in March/April, quarantined the suspected and ill patients, and it largely went away by the end of May. By that time, the rest of the world had largely stopped travelling and Liberia was able to nearly return to “normal”. People wear masks indoors, don’t hug or shake hands, but other than that it is just normal life here. I worry that as travel becomes more normal there will be a big outbreak here and I’m grateful people are still being fairly careful, but, it is incredibly relaxing to be in a place without the shadow of last year. Here’s hoping Liberia can stay out of the pandemic.

The rest of week 1 went as expected – getting set up. We have a new apartment, had to get running water and electricity set up there…Trusty Rusty, our pickup, needed some service…and we had meetings with all of the staff at the hospital to set up plans for the rest of the trip.

            The hospital has held up well over the past year. We see more patients every week and have received national recognition as a Center of Excellence by the Ministry of Health. Since I was last here, we have opened up our inpatient units, have overnight patients regularly, and established both OB/GYN and surgical programs. Everything at the hospital is great. Our only downer is that we lost Dr. Mercedes, our Cuban specialist, at the end of March. Cuba called her back indefinitely due to COVID-19. Fortunately, we found Dr. Efosa, a Nigerian infectious disease physician and surgical specialist. Our main focus at the hospital this trip is expanding the laboratory.

There was also a national holiday on Thursday this week (Armed Forces Day), so, we only had a four day workweek. But, things are set up nicely for next week and the rest of the trip.