Vol. 17 • Issue 10 • Page 50
Person to Person
In a country with historically limited financial resources, a shortage of health care professionals, inequitable distribution of health care manpower (with about 90% in urban areas, leaving the majority rural population underserved) and inaccessible health facilities, the Republic of Liberia's need to train health care providers was as acute in the 1960s as it is today.
With Liberia's disease pattern comprising mostly preventable ones (especially childhood communicable diseases), the government years ago resolved that training midlevel primary health care providers was of paramount urgency.
Thus in 1965, a physician assistant program was established through the Ministry of Health and Social Welfare in collaboration with the World Health Organization (WHO), the United Nations Children's Fund (UNICEF) and the U.S. Agency for International Development (USAID).
As deputy chief medical officer and head of Liberia's Bureau of Medical Services from 1981 to 1986, I was in constant touch with the director and students and participated in the curriculum development, reviews and teaching.
Liberia's Early PA Program
The Liberian PA program began as a health assistant program to train young men (women initially were excluded) to provide health care to rural communities. In the beginning, the training center was at the Lutheran Mission's Phebe Hospital in Suakoko, Bong County; later, it moved to the Liberian Government Hospital in Monrovia.
Entrants were eighth- and ninth-graders; training lasted 12 months. The low educational background deterred many students from coping with the curriculum's intensity and comprehensiveness, so later the admission requirements were changed to include only students with three years of high school, and training was extended to 18 and then 24 months. The program's name was changed from health assistant to physician assistant.
In 1975, the PA program became a school of the Tubman National Institute of Medical Arts at the John F. Kennedy Memorial Hospital in Monrovia. That year, the curriculum was revised to ensure that training was comparable to PA programs elsewhere. The training period was extended to three years, and a high school diploma became a prerequisite for admission.
Faculty and Curriculum
The program's first director was Agnes Dagbe, and her faculty included Americans J. Paul Martin, MD (who later would become founding executive director of the Center for the Study of Human Rights) and Paul Getty, MD (who later would become founder and director of Liberia's national leprosy control program), and Liberian Kate Bryant, MD (who would later serve as Liberia's minister of health and welfare), to mention a few.
Dagbe left Liberia in 1980 following a coup d'etat and was succeeded by a series of directors, including a Jessie Ebba-Duncan, who is now Liberia's assistant minister and deputy chief medical officer for preventive medicine. In the early 1980s, American K. Mona Moore, PA (now at the CAEAR Foundation, in Washington, D.C.), was on faculty. The current director is Abraham Johnson.
The program curriculum is divided into three stages: didactic, clinical rotations and preceptorship. The first- and second-year courses are followed by clinical experience, with several weeks spent on observation and participation in order to acquire basic knowledge. The third year is mostly for preceptorship and affiliation. Students go to rural clinics and hospitals, where they work with physicians, nurses and other health care professionals with whom they eventually might work upon graduation.
At the end of their preceptorship, all successful graduates take a certification examination under the auspices of the Liberian Medical and Dental Association Board. Those who pass are issued licenses as registered PAs, with rights and privileges to practice general family medicine under physician supervision.
Advancement for PA Graduates
Before I left Liberia in 1985, I was working on upgrading the academic credentials of PAs from a certificate to a BS degree. Several general and unofficial discussions were held with minister and assistant minister of health and social welfare, then-program director Jessie Ebba-Duncan and county medical directors.
With WHO sponsorship and assistance from other nongovernmental agencies including USAID, our PAs could enroll at the Fourah Bay College at the University of Sierra Leone for a nine-month certificate in tropical community medicine and health. This could be followed by a two-year postgraduate diploma course in tropical medicine and hygiene; this qualification then would enable the PA to pursue a master's degree in community medicine and health for a one-year period at Liverpool School of Tropical Medicine, the University of Liverpool or the University of London School of Hygiene and Tropical Medicine, all in England. The graduates from any of these schools would then qualify as community and public health officers to work in primary health care, or to become instructors at the PA school. Other possibilities, such as specialty training in any branch of medicine or matriculation to medical school, also existed then for Liberian PAs.
Abdul Massaquoi is the academic coordinator for the PA program at San Joaquin Valley College in Visalia, Calif.