Polluted waterways and physician shortages
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* Christopher Mason

It is difficult to comprehend that some 75 000 people live on the tiny swath of land known as “West Point,” pinned between the Atlantic Ocean and the swampy banks of the Mesurado River in the downtown portion of Monrovia, the capital city of Liberia.

In West Point, there are “too many” people and not enough of many more, namely, doctors.

A single doctor serves West Point’s residents. But that doctor is also responsible for two other clinics elsewhere in the city, so he is available, at best, four hours a day.

“With the lack of safe drinking water, few toilets and not enough food, so many people get sick,” says Donna Dennue, a resident of West Point and a member of a community organization called West Point for Health and Development.

West Point is not alone in facing a shortage of qualified doctors. It is a country-wide problem severely hampering efforts to strengthen the health of a population deeply affected by decades of instability.

At last count, Liberia had 130 doctors, 51 of whom are Liberian, serving the country’s 3.5 million citizens, according to the World Health Organization. Aid groups say Liberia needs at least 1000 more doctors. Likewise, Liberia’s estimated 600 nurses are a fraction of the 4800 the Ministry of Health and Social Welfare says are needed.

Liberia’s 14-year-long civil war came to a head when former President Charles Taylor — now on trial for 11 counts of war crimes and crimes against humanity at The Hague — was sent into exile in 2003. By that time, the ranks of health care providers were decimated, while 95% of the country’s health facilities were destroyed or made nonfunctional, according to the United States Agency for International Development.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/182/14/E689/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/182/14/E689/F1)

The shoreline in West Point, Liberia, where trash and ramshackle latrines pollute the water that residents use for washing. Image courtesy of Emily Brennan

Reconstruction efforts focused on restoring a semblance of normalcy to the health care system and the traumatized population. As recently as 2007, 70% of Liberia’s health facilities were operated by nongovernmental organizations, while the country’s sole medical school, the A.M. Dogliotti College of Medicine, graduates only a handful of students each year, instead of the 40-plus it graduated annually before the civil war.

The government, with help from international donors, is trying to strengthen the medical school through refurbished facilities, new textbooks, higher pay for instructors and programs to bring in international doctors and professors to teach and offer some front-line medical services.

“International doctors come for a short time, often one week or two weeks, then go,” says Dr. Bernice Dahn, Liberia’s deputy health minister and chief medical officer. “We hope to develop programs that would encourage doctors to come for six months to a year and really take part in substantive work.”

The current class is nearly 50 strong and it’s hoped as many as 35 will graduate five years from now.

The government is also seeking ways to strengthen international training opportunities for Liberian doctors and medical students, without increasing the risk that they will not return home after the training. As with many sub-Saharan African countries, Liberia is struggling to convince their health workers to stay rather than seek opportunities elsewhere.

Negotiations are underway to establish relationships with other countries such as Ghana, Nigeria, South Africa and Kenya to allow medical students, including those seeking specialist training, to study at their institutions. The thinking is the training will be cheaper, and it will be easier to ultimately convince them to practice in their home country.

“You send them to America or any other country overseas for medical studies and they will not come back,” says Dr. Tabeh L. Freeman, Dogliotti’s dean of medicine. “With little money we can train a whole lot of them in South Africa or any other African country.”

Liberia’s Ministry of Health and Social Welfare is also pursuing short-term solutions to provide front-line health care while the medical ranks are being regenerated. Those include a training program for midwives and plans to train nurses to perform emergency surgery when doctors are unavailable.

The goal of the midwife program is to expand the current roster of midwives to 1600 from 400, while bolstering their level of training, particularly in rural communities.

But even once the shortage of physicians and other medical workers is resolved, Liberia won’t be out of the woods. Less than 25% of the population has access to toilets, and only 32% can access safe drinking water. The WHO links one in five deaths to lack of proper water and sanitation.

Communities like West Point illustrate the challenge. Its 75 000 residents often have nowhere to turn when they fall ill from using the same water for cleaning and bathing that is polluted by those who use the many ramshackle wooden latrines hanging out over the waterways. After all, there is only one doctor.

## Footnotes

*   Published at [www.cmaj.ca](http://www.cmaj.ca) on Sept. 7