Liberia is a country located on the West African coast bordered by Guinea, Sierra Leone and the Ivory Coast. Founded in 1821, it is Africa’s oldest modern republic and was established on land acquired for freed US slaves by the American Colonization Society. The territory was named Liberia (Land of the Free) and boasts vast amounts of natural resources. It has strong historical ties to the USA who, between 1962 and 1980, donated $280 million in aid to Liberia, in exchange for rent-free land for its government facilities. Between 1989 and 2003, a civil war broke out in which an estimated 250,000 people lost their lives. Ellen Johnson Sirleaf became the first African female president in 2005 and was awarded the Nobel Peace Prize in 2011. The country is rebuilding itself and, in this article by Dr Tabeh Freeman, we get an insight into ENT in Liberia from his perspective as the only ENT surgeon in this country. He appeals to the readership, particularly Liberia’s US cousins for help.
The decline of ENT in Liberia
Liberia is situated on the west coast of Africa with a population of 4.5 million. It is divided into 16 counties and five regions. The country is known for its natural resources, including the famous Firestone rubber plantation, the largest in the world.
The health sector was devastated by the 16-year civil conflict, leaving the country vulnerable to preventable and treatable diseases. Ear, nose and throat services were last available in the country from 1972 through 1980, which was mainly offered by foreign nationals and focused only in the capital, Monrovia. Three years before the beginning of the civil conflict in 1989, a Liberian returned with a one-year diploma in ENT and started providing basic ENT services but with lots of limitations including lack of proper equipment. Furthermore, they were not fully trained to carry out most ENT procedures. Subsequently, the first civil conflict started in December of 1989. It led to the total destruction of the health sector, leaving the citizens vulnerable to their diseases. After the war, the country’s health sector suffered another setback when, in 2014, the Ebola outbreak swept the entire nation. It left nothing in its path and further damaged the health sector.
Dr Freeman performing an otoscopy examination on a patient.
From 1989 to 2022, the only access the citizens had to ENT services was through mission trips and short-term visiting doctors. Without that, citizens would travel to nearby Ghana if they could afford it. Otherwise, they would stay home and die from their diseases.
A new hope
In December 2022 the country received its first fully-trained ENT-Head and Neck Surgeon (me, Dr Tabeh L Freeman Jr, a Liberian) since the country’s independence in 1847. I started seeing patients on 6 January 2023 at the nation’s number one referral hospital in Monrovia and, so far, there have been a variety of cases coming from most parts of the country. The majority of these are cases related to hearing loss, resulting from avoidable causes, such as poorly treated ear infections and administration of ototoxic drugs.
"From 1989 to 2022, the only access the citizens had to ENT services was through mission trips and short-term visiting doctors"
The health system is still very poor. Citizens have little to no access to timely, appropriate healthcare, and develop serious avoidable complications.
The problems
There is a huge need to reestablish ENT services in Liberia. However, little has been done to tackle the problem. In the outpatient services, I am able to do basic otoscopy and treat ear infections. I am, however, unable to do a proper aural toilet due to the lack of microscope and ENT workstation that would provide me with micro suction; as a result, these patients with discharging ears need to be dry mopped.
A one-year-old child aspirated peanuts for a week and with subcutaneous
emphysema, but there is no means of doing a rigid bronchoscope.
There is no means of doing a flexible scope in the clinic for patients with voice and laryngeal issues, therefore patients are usually taken to the theatre under light sedation for a ‘direct laryngoscope’ using the anesthesiologist’s video laryngoscope for diagnostic and therapeutic purposes. Tympanoplasties are done endoscopically using the urologist’s fibre optic paediatric cystoscope due to the lack of a rigid ear scope. FESS is done in a similar manner. Head and neck cases are usually done with not much difficulty due to the minimum resources required for these cases.
For patients with hearing loss, there are no means of doing proper and comprehensive audiometry and definitely no means of providing hearing aids. Many patients have come to my clinic with hearing aids that were sent to them by their relatives in Europe and America hoping that they will work but, because they are not programmed, they usually don’t.
Final words
These are a few of the many challenges that I am facing in trying to establish and sustain a fully functioning ENT unit in Liberia. Quitting is not an option because these patients have been waiting their whole lives for ENT care and, now that they have their own fully-trained ENT surgeon, there is hope that one day basic equipment will be provided in order to attend to the huge ENT needs for the dying citizens of Liberia. I appeal to the global ENT community to help me achieve these goals.
