Editor’s Note: This story is the second of three profiles documenting new energy and medical projects funded by Direct Relief in three West African countries: Sierra Leone, the Gambia, and Liberia. The first can be found here.

A patient urgently needed oxygen, but the hospital’s supply was down to one cylinder — not enough for the case and certainly not enough for the 700-bed facility to get through the night.  
 
Edward Francis Small Teaching Hospital is an essential research and referral hospital in Banjul, the Gambia’s capital city. It is the most critical healthcare institution for the national health security of the country. But until recently, sourcing, transporting, and paying for oxygen canisters for patients were a massive drain on hospital resources. The only oxygen available was industrial, not the more effective medical-grade oxygen. Canisters were carefully rationed, frustrating providers and making it harder to provide surgeries and specialized care. 
 
Dr. Mustapha Bittaye, the hospital’s chief medical officer, explained that staff members needed to wait in a queue every two weeks at an industrial oxygen plant to purchase about 350 canisters. Purchasing the oxygen — if it was even available — might cost 2 million dalasi, or about $28,000 USD, per month. Sometimes oxygen costs more than the entire revenue the hospital collected that month.

The effort and expense it took to meet one critical need is a testament to the hospital’s dedication to its most vulnerable patients, such as newborn babies and the critically ill. But the disproportionate allocation of resources hampered preventative care, teaching, research, and the expansion of medical services.

“It was very common to have many people employed…just moving the oxygen around,” Dr. Bittaye said. “It was very common for supplies to be short. You only give it to those who need it badly…you had to do rationing.”  
 
The complex oxygen piping systems employed by many hospitals allow physicians to customize oxygen concentrations to individual patients, like premature infants, who have specialized needs. They allow surgical teams to use a built-in suction system rather than an external device. Edward Francis Small Teaching Hospital, which operates in conjunction with the University of the Gambia, trains surgeons and other specialists with the goal of eliminating the need for outside medical missions, but its colonial-era facility didn’t have an oxygen piping system or a plant to produce the medical grade oxygen required. 

Now, a new medical oxygen plant has been completed at the hospital, and a pipeline system developed to distribute the operating theaters and oxygen throughout the facility. Biomedical technicians are being trained to maintain the new system over time. 
 
The new system has rapidly changed healthcare in the Gambia, said Dr. John Sampson, a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine who works closely with medical partners in West Africa. Now, a new anesthesiologist, who recently graduated from medical school, makes full use of the medical oxygen system in her work at Edward Francis Small Teaching Hospital.
 
“The hospital is transforming very rapidly,” Dr. Bittaye said. Average monthly revenue has sharply increased, and more specialists are completing training. But for his providers and staff, the increased quality of care, and better outcomes for patients, are the most important considerations. 
 
“Most important is the patient,” he said. “No more rationing, that’s the biggest thing.” 
 
The medical oxygen plant and distribution system are part of the larger Africa Infrastructure Relief and Support, or AIRS, project – a Society of Critical Care Medicine collaboration with the Johns Hopkins Global Alliance of Perioperative Professionals, or JHU-GAPP, and the Institute of Global Perioperative Care. (Dr. Sampson founded the last two organizations, and is GAPP’s executive director.) Through AIRS, Direct Relief is funding reliable power and medical oxygen projects in Sierra Leone, the Gambia, and Liberia, with a $5.5 million grant. 
 
International groups have worked to supply major hospitals around the world with oxygen plants for years, but frequently these hospitals are reliant on foreign workers to fix broken systems. When support is slow to arrive, hospitals are without medical oxygen once again. To prevent this, the AIRS project also includes extensive training for local biomedical engineers, who will maintain the plant and distribution system and repair as needed.  

Because power spikes and other electrical phenomena can damage oxygen systems, Edward Francis Small Teaching Hospital’s system is specifically designed, by a Ghanaian installer who has experience with the region’s grids, and knows how to insulate the plant from shocks.  
 
“Obviously the amount of effort of well-meaning Westerners over past years has been in the millions of dollars,” Dr. Sampson said. “But no one is addressing the core infrastructure issues that prevent the health care providers who were born, who were trained, who live, who teach [in the Gambia], and who care for their people” from providing the care which they are so capable. 
 
Dr. Sampson explained that Westerners often misunderstand the nature of health care in countries like the Gambia. West African countries train and develop their own accomplished physicians, and hospitals are staffed by skilled, committed providers. For many health systems, drastically reducing the need for foreign doctors is a high priority. But to accomplish that, high-quality medical infrastructure and reliable electricity are indispensable. 

Without necessary resources like medical-grade oxygen, West African providers may feel frustrated and disempowered, Dr. Sampson said. A surgeon may be highly talented, dedicated, and trained in state-of-the-art techniques, but performing surgery without reliable electricity won’t allow them to care for patients to the best of their ability.  
 
Choosing the AIRS projects and the best locations for each required working with regional experts, health ministry authorities, and medical and cultural partners across West Africa. The Gambia’s new medical oxygen system is intended to strategically meet the needs that health systems, hospitals, and providers encounter in their communities every day.  
 
“Our program has taken a different approach to global health,” Dr. Sampson explained.  
Now, the hospital’s leaders “can actually use their money for health care instead of cylinders.” 
 
“That’s what I love about this project,” Dr. Bittaye said. “It’s the holistic nature of it,” with partners asking what a hospital needs and what its goals are, rather than offering something that may fit an outside mission but doesn’t suit a country’s own approach to health care.  
 
“It’s going to have a big impact,” he said.