Because of the extreme need for medical care of any kind in Liberia, Africa, this clinic was designed to function as a small hospital as needed. The space is efficient and minimal, as space is a commodity in Liberia, the poorest country in the world.
Multidisciplinary Social Justice Cultural emphasis Economic Diversity Construction varying by location
Tasha Urban
ThefollowingisaninterviewconductedwithKimBarker.KimBarkerwasMLS(MemberLeader Support) for the Monrovia, Liberia Africa mission for the Church of Jesus Christ of LatterDay Saints. She spent approximately two years in Monrovia. Part of her duties was overseeing all medicalissuespertainingtomissionariesinthatarea.
M e : Can you tell me a little bit about what life in Liberia is like, in regards to medical care?
K i m : Our hospitals can’t legally turn us away, but over there if you can’t pay you don’t get help. Often, people would be beaten, robbed, and left on the steps of the hospitals or clinics. We would see them left there to die, because the clinics and doctors don’t have enough resources to help anyone who can’t pay for the help. You see more than half of the children with hernia navels, sometimes four inches long, but they don’t have money to take care of it, or a shoddy job meant it came back. Many children’s eyes are popping out of their heads big as boiled eggs because of pressure from glaucoma, or they have growths on their necks. There was a woman who had broken her leg seven years ago, but had never been to a clinic. Every day she woke up, tied a bandana around it, and hobbled around with a cane while her leg dangled and dragged behind her. In Liberia we tell people ‘if medical treatment includes drums or chanting, then run!’ And it’s true! Witch doctors will set up phony clinics there, so you have to be careful!
You start at the outbuilding in front of the clinic, go in, and give them your name. If you had a card with your name and number from a previous visit, they look for your file. Otherwise they give you a piece of cardboard that looks like it’s been used for a year, with a number written on it with a colored marker. That determines when you get in to see the doctor. They also give you a 1”x ½“ card with your name and the same number. From there you can go inside the actual clinic to the clerk’s window and give them your paper card and they’ll look for your file. Their filing system is just shelves packed full of stuff and tables stacked neck deep. It’s so unorganized! Anyway, there they give you an invoice for 200 LB, which equals $1.60.
M e : Can you walk me through the process of taking someone to the clinic?
Then you take that invoice to the cashier’s office, and until you pay, they won’t even call you in to get your temperature taken. Everything there is on a cash basis only: no billing, no credit cards. Once you’ve paid the 200 LB, you go sit on a wooden bench and wait. The waiting room has wooden benches, no chairs. We’ve sat there for hours all day once, just to see the doctor.
A nurse will call you back and take your temperature, weigh you, and ask why you’re there. Then you get sent back to the waiting room until the doctor is ready to see you. The area for triage (blood pressure, temperature, weight) is the size of an average sized bathroom; remember, space is a commodity there.
Oh, there’s another room for IV and medication that’s separate from the lab. The room was as small as the main part of a trailer, and had four beds where you could just lay there and get your drips, which takes about 45 minutes.
Gillian was the doctor at our clinic. You would see her in her scary office. Gillian’s office has a desk, closet, sink, books, table, and a couple of chairs. That was her office and often her operating room. She’ll take care of you right then. If you have an ingrown toenail, she’ll treat it right there in her office. She’ll ask you questions and write down labs.
Next you go back to the cashier and pay for the labs, and they’ll process them while you wait in the waiting room. Then the lab results go to the doctor, and when she has a free minute she’ll call you back in and give you the diagnosis and prescription. You take your prescription to the pharmacy window to get a price. Then take the prescription back to the cashier and pay for it. Then you can go back to the pharmacy and pick up the medication. After all that, you can go, but you have to show security your receipts before you leave the clinic to prove that you paid for everything.
K i m : Security there is 24/7, and if you don’t show them your receipts, you don’t leave. There are bars over all the windows, because otherwise people will break in, and there are security guards at all the entrances.
K i m : People do spend the night. There’s an aide station upstairs for hospital overnight rooms. Patients have to pay before they spend the night there, and if they don’t pay, they’ll be put out on the street. They don’t have kitchens, so unless someone brings them food, they’ll starve. Locals will cook meals outside, and workers can order food like rice and Liberian soup. The cooks will bring the orders to the clinic, where a security guard will stop and make them taste the food in front of them. People get poisoned all the time over there, so they have to taste it in front of the guards. They just stick their bare fingers in the food to get a taste, which turns my stomach, because let me tell you: hygiene over there is horrible! You don’t want their hands in your food! Once they’ve tasted it, they can continue inside and give to whoever ordered it.
K i m : Sanitation is really bad compared to U.S. standards, but that’s what they have. Gillian has disinfectant hospital grade wipes, and uses gloves all the time. I’m sure they have disinfectant wipes in the drip area and in the lab. The waiting rooms and bathroom were filthy and deplorable. The bathroom (only one toilet) didn’t even work, and there was grime everywhere. People waiting would just walk outside and pee on the side of the building before coming back inside, even the women.
ThefollowingisaninterviewconductedwithArvidCarlson.ArvidCarlsonworkedfortenyears intheER,thenstartedhiscareerasafamilydoctor.Afterthathejoinedtheforeignserviceand worked as a family doctor at embassies all over the world. “We lived in India, but I’d go to PakistanonMondaysandTuesdays, Calcutta or MumbaionWednesdays andThursdays,and BangladeshonFridays.”HehaslivedandworkedinIndia,Hungary,BuenosAires,HongKong, and Monrovia (to name a few places) and regularly travelled to 20 50 different cities and countrieseachyear.
M e : Can you tell me a little bit about what life in Liberia is like?
A r v i d : One time I called the landlord because we had bought a washing machine we were lucky enough to find, and he said he’d send an electrician by to plug it in. The electrician asked for a butter knife to run the screws. “Would you like a screwdriver?” I asked. “You have a screwdriver? That would be awesome!” he said. The electrician didn’t even have a screwdriver.
There was a mission leader who once spent two hours teaching a class on how to read a tape measure. They don’t have screw guns or screws; they put everything together with hammers and nails. The Lebanese build the hotels and stuff like that, and the Chinese build the roads, but there are really no skilled craftsmen in the country, and they have no concept of good construction. Wood is cut by saws; they just measure it by eye. A lot of them have never even seen a table saw. They build with what we call ‘T LAR. That Looks About Right.’ You can design a beautiful building, but there’s no one there who can construct it.
Most of the walls over there are concrete block (all handmade, one at a time. There’s a whole industry there sand, concrete, water, packed in wooden molds, left in the sun to dry. People make their livings in their backyards doing this, one block at a time. These blocks aren’t consistent or reliable because they’re cheap, shoddy, and homemade). Most of the buildings have corrugated tin roofs. We’re talking like… they don’t have anything. 80% of the people over there don’t have toilets, they just have a screened area. They haul water from wells and have to walk for blocks, or they buy it from vendors. The clinics are very similar. If you put a concrete floor down and paint it, they think it’s wonderful.
M e : On average, how many people were treated daily in clinics?
A r v i d : In some places that could be 20 40 a day.
M e : How many people stay overnight on average?
A r v i d : In Gillian’s clinic, anywhere from 8 10 at any one time. They had about that many beds. In the big government hospital (JFK), they have 3 400 staying there, but it’s not a good place to be. The locals say “JFK” stands for “Just For Killing.” They only go there if they think they’re going to die, because most people who go in don’t come out. In Gillian’s clinic, the rooms have concrete floors, concrete walls, a bed with a foam mattress, and openings in the walls with screens high up to be mosquito proof but to let in light. They don’t have air conditioning, just fans; AC just draws too much electricity.
M e : How many/what kinds of rooms does it need?
A r v i d :
- Surgery/operating room for C sections, etc. Gillian has a nurse trained to give anesthesia. They also have a generator.
Two offices for doctors. If there are two doctors, they can see twice as many patients, but they’re only set up to do two physicians/doctors at once. They have a hard time keeping more than two doctors at a time, due to the nature of the job over there.
- Office manager’s office at the front Nurses take vitals in a couple of rooms. People show up early in the morning and get in line, and the first people in line are the ones who get to be seen. It’s recommended you get there by 6 a.m., and the doors open at 8 a.m. They have benches, tons and tons of benches, for people to sit and wait to be seen. So have a bigwaiting room. You might have 40, 50 people waiting for hours, sitting all day to be seen.
File room/clerk area. Everything’s done on paper, no computers. They have walls and walls of files.
No kitchens. People bring them their food. There are no refrigerators, so there’s no food storage, and it has to be brought fresh every day.
M e : How big do the rooms need to be?
A r v i d : The bigger you make them the more materials you have to pay for. Space is a premium. Most of the rooms over there are 8’x8’ 10’x10’.
M e : What spaces are required for equipment?
A r v i d : Storage
People donate equipment old x ray machines and things like that but they don’t have any film for it, or any way to fix it, or any of the chemicals to develop the film.
You need space for X ray machines, microscopes, but if you don’t do service on them they don’t work and just sit in storage
M e : What is the size of staff?
A r v i d : At Gillian’s clinic there are 1 2 doctors, an office manager, 10 nurses (they take blood pressure, draw blood, etc.), paperwork staff, a “pharmacist,” and cleaning people. They don’t pay much there I know a schoolteacher and his family there who live on $65 a month, and they live comfortably by Liberian standards.
M e : Do staff members need living quarters?
A r v i d : The physicians, absolutely yes, need a place to stay. Most other people are going to go home at night. They take public transportation, which is basically made up over individuals who own a private van. They take the seats out of them and put wooden benches in there to fit more people in, as many as you can get in there: up to 20 people in a van. It could easily take them 1 2 hours to get home at night.
M e : What would you like sanitation to be like?
A r v i d : Showers, and stalls. Most of the time you can get water from tank trucks, that fill up the tank on the roof. It can flush the toilets and run cold water to your shower. Sinks and toilets would be nice (but there’s no hot water). You only need one faucet. To have a water heater, you have to have gas or electricity to heat it, and that’s very expensive.
Most people cook over fire or charcoal. Missionaries were some of the only people in the country who had little “camping” stoves.
M e : Should there be a conference/business area for groups such as Doctors Without Borders?
A r v i d : Yes! They’d love to have a meeting place where they can do teaching and training. That’s hugely important. There needs to be education going on all the time. They’d love a bunch of chairs, and a table, and blackboard with chalk. If you have a good generator you can do computers and projection, etc. Most of the time you just wish they had a chair and a table, made with screws, not nails. A training area would be wonderful. And a little community lunch room would be awesome to keep food out of the work areas, and give you someplace where you have a clean place to eat.
M e : What do you wish you could change about the current clinic?
A r v i d : No carpet. Places flood every year.
You want floors you can hose down, like concrete, painted concrete, maybe tile.
- Glass would be good, and more than a lightbulb on the ceiling. If the generator keeps running, that’ll be good too. They have flushing toilets and a generator, but those are the exceptions.
- If we had a water tank on the roof that was good, or sometimes there’d be a well in the yard.
If they do have AC, they’re individual wall units that hang up at the ceiling, bolt to the ceiling with a hole that goes through the wall to the compressor outside (1’x1’).
A r v i d : Gillian’s doing the best she can, and people are still dying every day.
Gillian Seton is 37, single, and the general surgeon and medical director at the SDA Cooper clinicinMonrovia,Liberia.Thefollowingareexcerptsfromtheemailshetookthetimetosend me when I asked her about her clinic. We are in a constant state of flux, so it's not so easy to answer, but I'll try to get through your list.
• How many people (on average) are treated daily? In clinic: 30 45; usually 1 4 people admitted from ER or clinic
• How many people (on average) stay overnight? 8 15
• How big is your clinic? We have 1 2 doctors most days in clinic.
• How many/what kinds of rooms does it need? We are working with a very small space. 5 exam rooms (3 of which are doctors' offices and double as exam rooms). Also need more office space for administrator, business manager, accounts, payroll, etc. Shielded room for XR, a small room for ultrasound/EKG.
• What spaces are required for equipment? Always could use more space, a secure closet for storing equipment and keeping it clean and dry (major challenge) and free of mice/cockroaches. Equipment could be paper supplies, small instruments like otoscope, dressing supplies for wound care, etc.
• Do staff members need living quarters? For doctors, yes.
• What would you like sanitation to be like? For Liberian circumstances, everything has to be self contained. Our own septic tank(s), our own incinerator, ash pit to dispose of incinerated metals like needles and other debris, our own placenta pit. Plumbing needs to be accessible (external to the cement block walls). Need hand washing sinks in every exam room and nursing stations.
• Should there be a conference/business area for groups such as Doctors Without Borders? Yes to conference room, for teaching, staff meetings, visiting groups
• What do you wish you could change about the current clinic? Just about everything as the space was built with different purpose in mind, then added to over the years.
Items that are needed:
Triage/screening area with sitting space, isolated desk for the screeners. 1 to 2 normal exits for people going to the clinic area
Large waiting room with plenty of windows for light and ventilation. Small room for checking vitals/weight. Large record room
Bathrooms (separate for female/male) for patients/visitors
Offices needed for clinic in additional to medical exam rooms: Cashier/payment office
Outpatient pharmacy (best if connected to large storeroom for drug and medical supply storage)
Laboratory
XR room (needs shielded walls)
Ultrasound room
Offices/support staff Conference room
Offices for administration, admin assistant, business manager, HR, accounts, payroll, etc. Some could share offices.
Janitorial room: space for supplies, large utility sink maybe. Staff bathrooms Staff break room
VERY large storage area (we often get supplies donated with years’ worth of supplies and need a good place to store them. Cool, dry. NO windows given the dust, access to rats, etc.
Inpatient needs: Bathrooms for staff?
Semi private rooms (2 patients each) with own bathroom. We currently have 5 and these are the most commonly used rooms.
If two story building, a gentle ramp is much better than elevator (which only break down). Ventilation is very important, given the heat and humidity: tall ceilings, ability to open windows/vents to allow for cross breezes. Hope that helps!
Let me know if you have more questions. Gillian
The exam rooms are designed to be quickly built and efficient. The floor is concrete covered with vinyl to keep the space easy to clean even when the building floods, as is common in Liberia during the monsoon season. However, the blank cement block walls provide the perfect place for local artists to incorporate their colorful culture.
Liberian culture is vibrant and color-filled. A Vogue writer living in Liberia points out that when “we see a gold dress [...] we think, How will this look on my body? They [...] think, This is a beautiful color; I want to wear it.” Liberians are not afraid to incorporate color in every aspect of their lives. Incorporating color into the exam rooms with scenes of Liberia will make the spaces feel more familiar and comfortable.
Good construction in Liberia consists of concrete floors (luxuriously covered with vinyl or linoleum if you’re lucky) and walls built from homemade cement blocks. These walls are often coated with stucco or mud.
For most homes, the walls have to be rebuilt as they crumble during monsoon season. Tin roofs are common, as is painting the concrete walls brilliant and vivacious colors.
The clinic features two wings and a covered walkway around both. Benches line the front of the one of the wings, near the doors to the clinic waiting area, so that even during the rainy season visitors are kept dry.
