Highlights of the Year

Some of my favourite memories from my time in Sierra Leone….

1) Decompressing a tension pneumothorax.
2) Seeing that little boy come back to see me and say thank you.
3) Anytime a mother or father said “I tell God tenki” to me.
4) My birthday – lots of singing “Happy Birthday”, a happy day at hospital, fish carpaccio, red wine and an amazing chocolate cake!
5) Seeing the little girl with pneumococcal meningitis alive and well.
6) Jumping into the IMATT pool at the Royal Wedding Party.
7) Winning the money tree at the IMATT Christmas party.
8) Rugby afternoons with Freya and the IMATT crew.
9) Listening to the beautiful singing of the choir from Wells Cathedral School.
10) Meeting Andy from the Pelican and generally the whole time Andy was here.
11) Getting lost up Sugar Loaf Mountain.
12) Mum and Dad’s visit, especially The Burn’s Supper at IMATT, Banana Island and visiting Connie and Lavan in Kabala.
13) Seeing Andy at Heathrow airport.
14) The Mercy Ship Anaesthetists’ Conference.
15) Being at the Stadium on Independence Day.
16) Seeing Andy whenever Skype video worked (which is not very often!)
17) Seeing a little boy with an empyema coming back for follow-up.
18) Sunsets, great company and fabulous food at Hamilton and Tokeh beaches.
19) Being at Tacugama and Hamilton with Selena.
20) Occasional afternoons when it was quiet enough at the hospital to have fun gossiping with the nurses.
21) Receiving news from home that best friends had had their babies.
22) Seeing the father of a patient with Down Syndrome who came to thank me for putting them in touch with an occupational therapist.
23) Being recognised by various patients’ mothers whilst out and about in Freetown, and them thanking me again for helping their children, including the mother of a child who died who I met at Congo Cross and wanted to say thanks for everything I tried to do.
24) Any time we got running water again after being without it.
25) Dancing with friends to Salonean music including Waka Waka Baby and I love my life.
26) Finding out that Susan one of the other VSOs used to work with my Dad in Shetland!
27) The bizarre party at the hospital – dancing with the nurses, doctors, patients and little kids who live under the stairs at the hospital.
28) ETATing in Kenema
29) The Welbodi Quiz at IMATT
30) My last visit to Hamilton eating yummy lobster in the sun (during rainy season).

How I Survived

1) With the support of my wonderful husband.
2) With internet access and mobile phone to be able to contact him.
3) Regular emails, facebook messages, thoughts and prayers from great friends and family at home.
4) My great little Welsh flatmate Cat who keeps me sane.
5) Carole, who explained how to get anything done in this country! And who also keeps me sane and gives out great advice.
6) New friends for life who have supported me emotionally through some incredibly tough times here; I am forever indebted to you all and thank you from the bottom of my heart for your friendship – and for putting up with me!
7) By taking malaria prophylaxis and sleeping under a mosquito net.
8) Wonderful visitors – Andy, Mum and Dad and Selena – thank you so much for coming to see me – it has meant so much that you know first hand what I’m talking about!
9) By the Grace of God. I once asked Sandra how she had managed to stay here and keep going for so long, and this was the answer she gave me.
10) The monthly service at International Church – a time for prayer, thought, and reflection (and great buffet bring and share dinner).
11) A bit of escapism - Bliss brunches, beautiful beaches, the UN pool Mamba Point dinners, nights out with friends.
12) By always retaining that bit of hope for the future of the children of Salone.
13) A few creature comforts from home – Earl Grey tea, pesto, the occasional bits of real cheese and chocolate which visitors brought out.
14) A lot of peanut butter.
15) IMATT. The wonderful hospitality at various parties, dinners and rugby games, military chat, great showers and just knowing they were there in times of need (oh and that swimming pool!)
16) Joe our fantastic neighbour who is always there to help with getting water, sorting out our electricity, being an excellent security guard (along with dog Tiger) and friend.
17) By going home for a break in April. I was cracking up a bit in March and was very very grateful for the break.
18) By knowing that I would be able to go home, to my wonderful husband, at the end of the year.

What Have I Achieved?

That’s it. I don don. I finished my placement at Ola During Children’s Hospital yesterday. When I was interviewed for the BBC by Fergus Walsh he asked what my legacy would be when I left Sierra Leone. I gave him a very blank look before answering. This, of course is the question which I have been asking myself all year. What have I been doing here? What have I achieved?

I can write a long list of patients I have treated, families I have spoken with, students I have taught, doctors and nurses I have worked with, health care workers I have trained in triage, nurse anaesthetists I have trained in neonatal resuscitation, audits I have completed and meetings I have attended.

These are of course quite personal achievements for me, things that I have done (and in NGO speak – would probably count more as “activities” than “outputs” or “achievements”). So perhaps it is better to ask what has changed at the hospital in the time I have been there.

On a day-to-day basis it is very difficult to see change. Especially with daily frustrations of staff coming to work late or not at all, patients presenting very late, babies being brought to S-C-B-U hours after they were born, the incredibly annoying pharmacy system (you have to re-prescribe all medications every day; it’s the bane of my life and the biggest waste of time), patients not receiving their medications, babies not being fed, patients not having regular observations, patients not being reviewed and asking people to do things again and again and again (only to find later it is not done).

However, over the time I have been here, I think that standards have improved. “Small small” as we say in Krio. Some (subjective) examples: many nurses are incredibly hard working, motivated and eager to learn. More children are receiving more of their medications. Observations are taken more regularly. The lab has certainly improved. The doctors are holding (more or less) regular morbidity and mortality meetings and other educational meetings. A perinatal meeting with the midwives has started. Children are prescribed quinine three times a day instead of twice a day. Standards of history taking and documentation are better. The under-5s clinic is now triaging their patients so the sickest children are seen first and transferred to hospital as soon as possible. ICU and ER have moved to a new location and there are now saturations monitors for children in ICU. There is more oxygen available for children in respiratory distress. There is running water more regularly (not all the time though!) Clearly there’s still a lot to do, but one step at a time.

(NB. Most of these changes have nothing to do with me being here but as a result of lots of people working together).

In reality I have not achieved very much in terms of change that can be measured. The mortality rate in the hospital is the same as when I arrived. It takes longer than a year and more than one person to make that sort of change.

So what did I say to Fergus Walsh? What is my personal “legacy?” The answer I gave him was the work I have done with the medical students. Twenty seven medical students who I have helped to train in paediatrics. They will graduate next year and become house officers here in Sierra Leone, rotating through the Children’s Hospital. Hopefully some of them will decide to become paediatricians, and to stay in Sierra Leone, and to share some of the skills I have taught them with others.

Things that have changed about me this year

1) I am more tanned than I have ever been in my life.
2) I have learned to be incredibly patient, but also how to be angry.
3) I have become a lot more sceptical about aid – that’s not to say I don’t agree with it (clearly I wouldn’t be here, nor on the BBC website, if didn’t agree with it!); just that I have learned to question how it is given, how it is implemented and what is actually achieved.
4) I have found that I really enjoy writing my blog!
5) I have learned a LOT about my own limitations, and the limitations of medical science.
6) I am very appreciative of simple things: running water, electricity, time, friends, family, health, laughter, hugs.
7) I hardly ever wear any make-up any more. (I am fairly sure this will change back as soon as I get back to Oxford though!)
8) I am better at coping when things don’t go quite to plan.
9) I am not fazed in the slightest when the electricity goes off.
10) I don’t allow myself to become frustrated at the slow internet.
11) I am much better at coping when the water goes off.
12) I now like drinking beer (but only Star).
13) I have accepted what I cannot change.

Blood Donation Mark Three

It’s been nearly four months since Sandra and I last went to give blood on Easter Friday. I really wanted to give blood again before I leave Sierra Leone (it’s on “The List”), so yesterday Becky and I headed to the blood bank to donate. Sandra is away and we missed you! My Hb was 11.4g/dl (theoretically a bit low to give) but I persuaded Omar to let me donate anyway (something tells me it might be a very long time before I can donate again in the UK). More pictures hopefully attached!

A Grand Day Out

With a limited amount of time left in Sierra Leone, Cat and I have written “The List” of all the things we want to do before leaving. Included on this list is, among other things, ETATing in Kenema (tick), eating lobster at Hamilton Beach (tick) and fish carpaccio at Mamba Point (tick). In addition, we planned a “Grand Day Out” in the East End (near the hospital) in order to visit a few “tourist” sites in the area. More of a “Grand Half Day” (as I had to do a ward round in the morning), we set off after a lunch of groundnut stew made by the family who live under the stairs.

First stop was the National Railway Museum in Cline Town. This was set up by a former IMATT colonel. There are no trains anymore in Sierra Leone (although the mining companies are now building a railway to transport the iron ore) but there used to be a railway from Freetown to Pendembu in the east of the country (365km). We had a fantastic guide who told us all about the history of the railway and showed us the restored rolling stock. The best thing was having a go on one of those things that looks like a see saw which you push up and down to move the wheels (if anyone can tell me what those are called I’ll be very grateful!) It was a lot of fun and we were all giggling like little kids when it was our turn.

Next stop was the Star Brewery in Wellington. We had wanted to see around it but alas it turned out that we needed to write to the general manager in advance to arrange a visit. Ah well, wi don try. It was also interesting to drive along the back roads as we saw the “Low Cost Housing” and other areas where many of the patients live.

To end our Grand Day Out we headed to 555 Spot, a bar on Bai Bureh Road where we met up with some of the nurses for a couple of drinks. It was good to see and chat with them outside of work and a nice end to the day. Many thanks to Alusine for driving us around.

Back in ICU

I’ve moved back to ICU for my last two weeks here in Freetown. ICU has moved since I was there before. It is in a new, smaller ward with only ten beds. It is a completely different atmosphere from the old ICU. The children are still extremely sick but we are trying to keep to a maximum of ten children (i.e. one to a bed), meaning that with fewer children to concentrate on they can get far more attention that previously. The nurses are now allocated patients, which almost works as it would at home. There are some continuous saturations monitors (meaning improved monitoring, although Cat and I are still the only staff who switch off the alarms). The children are getting observations done. They are getting their medications. They are getting fed. (All the above at least most of the time). On the ward rounds I almost feel like I’m in a normal ward in the UK.

When I remember back to the old ICU I often walked in with a terribly sense of dread thinking “which child has died in my absence?” or “which child will deteriorate and die in front of my eyes today?” Of course that possibility is still there but somehow everything seems so much more controlled. I’m very pleased to say that a lot of the children who were extremely sick at the beginning of the week were well and being discharged home by the end. The nurses clearly enjoy working there and they seem to know the children so much better than previously. Maybe it also feels more controlled because I am calmer too, more used to dealing with exceptionally sick children, I know what is and what isn’t possible to achieve here, and maybe because I know that I’m only here for a limited time now, so in a week I will not have to worry every day about how many children have died or are dying. For the nurses and doctors (and parents and patients) here, that burden will continue. They will continue to be in my thoughts and prayers.

On a happier note, Friday is Africana Day in Sierra Leone, when everyone wears more traditional clothes, so I wore my outfit to work again yesterday which got me lots of nice comments of “I like your style”. It was a good photo opportunity, so here’s one (hopefully) of me with one of the ICU nurses and a student nurse.

I’m leaving….

I think it has just dawned on me that I’m leaving Sierra Leone in two weeks time. I’ve known my leaving date for a while but I think I’ve been in denial. I’ve said goodbye to so many friends who have already left Sierra Leone (there is now only a select few of my NGO friends left here) and it seems strange to think that in two weeks time I’ll be the one getting on the Pelican water taxi to start my journey home.

I’ve been having a tidying up session this morning, throwing out things I know I won’t need, and sorting everything else into piles of things to take to the hospital, things to leave behind for friends and things I’ll take if I have space (clearly the blue dresses come first!) I’ve been listening to a mixture of Scottish and Salonean music and it’s making me both happy and sad.

I’ve also been looking through cards and messages that friends and family gave me before I left and letters I’ve received while I’ve been here. It makes me realise how lucky I am to have all those people at home and how grateful I am for their support.

It’s strange thinking back to when I left the UK, leaving home for a year. I know a lot of people thought I was crazy (I’ve thought this myself a few times). In the weeks leading up to leaving I was completely distraught at leaving my husband but at the same time I knew it was something I had to do. I cried all the way to the airport and kept trying to remember what on earth possessed me to put my husband and me through so much pain.

What a journey I have been on since then.

I’m so excited about going home to see my husband again, and to see friends and family from home. At the same time I am going to miss Sweet Salone so much; I have grown to love this country and the people, and I really enjoy the simplicity of life here. Once I get over that initial excitement of being home I guess I might find it quite hard to slot back into my life in the UK (particularly at work). It will take a while to hit me exactly how this year has impacted on my life. I guess I’ll need to take some time to reflect on everything I have seen and done and try to use all those experiences in a positive way when I get back home.

For now, it’s back to sorting out my room, enjoying my last few weeks left here and looking forward to the next journey.

Sounds, phrases and conversations that will forever remind me of Sierra Leone

(Apologies to any Saloneans for the spelling of Krio words and phrases)

1) “Ow di bodi?” “Di bodi fine, ow yusef?” “I tell God tenki”
2) “Aaaaaayyyyyy!” (an exclamation)
3) “Ebo!” (another exclamation)
4) “Plaintain chips chips”
5) “Col wata day wata day” (cold water there, said by the little kids who carry bags of water to sell in a bucket on their heads)
6) “Aba-daba-daba-daba-deen” (said by the ‘prentice in poda podas heading in the direction of Aberdeen)
7) “Can I have one more Star please?” (said by Fred)
8) “TFC?” “Yes” “OPD?” “Yes” “BBC?” “No” (a conversation I had with Sarah from Cap Anamur)
9) “Sheena Sheena” (what the little kids down our alley call me)
10) “Sowa sowa sowa lay” (the words to the ever present and popular song Waka Waka Baby).
11) The extremely distinctive sound of our gate opening and closing.
12) Beep beep (car horns tooting constantly).
13) The dogs howling at night.
14) “I no chook you” (I’m not going to inject you with anything, said by me to try to stop children crying so I can examine them)
15) “I go beat you” (I’m going to beat you up, said by the nurses to try to stop the children crying so I can examine them)
16) The “Gregorian chant” (as Becky calls it) music in Mamba Point.
17) The lilting sounds of the mocks (the mosque) near our house.
18) The wailing of the mothers outside ER and ICU when their child has died.
19) The beautiful sound of the Atlantic Ocean waves on the beach.
20) Hissssssssssssssssss/Tssss Tsss (used to attract people’s attention)
21) The so loud it’s sometimes scary thunder and massive downpours of rain that accompany it
22) “Oputo oputo” (white person – often shouted as I walk past)
23) “White girl” (ditto)

Survival of the Fittest

Imagine you are a child in Sierra Leone. Surviving childhood is a challenge. And there are so many challenges to get through. The first occur before you are even born. You are relying on your mother’s health, her education, her attendance at antenatal care, her compliance with antimalarial medication, tetanus immunisations and sleeping under a bed-net while she is pregnant. Then there is the challenge of labour and delivery. Will there be an obstructed labour? Will your mother develop chorioamnionitis? Will she present to health services at all? Will the midwife recognise a problem and alert the obstetrician if she needs a caesarean section? Will the midwives resuscitate you appropriately and take you to the S-C-B-U in a timely fashion? Or will your mother stay with a traditional birth attendant, in labour for days while the fetus (you) gets increasingly distressed, septic and hypoxic?

And if you need admission to S-C-B-U for hypoxic ischaemic encephalopathy, or septicaemia, will you get your medications? Will you get fed? Will you be kept warm or will you die of hypothermia? Will you get an infection from the baby in the cot next to you? Will you die of iatrogenic causes such as hyponatraemia, hypokalaemia or gentamicin toxicity because we can’t measure electrolytes and drug levels?

And if you are a premature baby your chances are even lower. However, the power for survival sometimes amazes me. We currently have a 700g baby said to be “9 months” (I don’t believe them, the baby is definitely premature and no one ever knows the true gestation). He is four days old and still remarkably feisty. He has a long long way to go, but it really is survival of the fittest.

If you make it past all that you are doing fairly well to start with. Then you go home with your family, provided your mother has survived childbirth – she has a one in eight chance over her lifetime of not making it.

If your mother hasn’t survived, you’ll be cared for by relatives, usually an auntie or granny. You won’t be breast fed, meaning you’ll probably get formula milk which has been watered down too much by unclean water. A recipe for malnutrition. And gastroenteritis. And if you make it to six months of age (starting complimentary foods) then you’ll have to fight with all the other children (once the men have eaten) for your share.

Meanwhile, if your mother did survive and you’re being breast fed, that’s a good start. Next you’ll have to ensure you get immunised (protecting you against polio, various causes of pneumonia and meningitis, TB – to a certain extent, hepatitis B, whooping cough, diphtheria and tetanus). The next thing to worry about is that dreaded Anopheles mosquito. Have your family got an insecticide treated bed-net? Do you sleep under it, protecting you from malaria? Or do your family find it too hot (the most common reason cited for not sleeping under bed-nets)? If you develop a fever or have a convulsion, will your family know that might mean malaria or another severe infection? Will they take you to a health clinic or hospital? Or will they take you to someone in the neighbourhood with a supply of medications and give you an unidentified injection (which could be quinine or ampicillin or gentamicin or none of the above)? Or will they take you to a traditional healer, buy some “native herbs” and suggest you are a witch or that it is “devil business”? Will they take you early to health care or will they wait until you are unconscious and moribund?

You’ve survived malaria/meningitis/typhoid/whatever severe infection you had (the hospital doesn’t really know what illness you had as they don’t have the lab tests, and anyway no one told your mother what was wrong with you). Next you worry about the terrible overcrowding in your house, the dreadful lack of sanitation and clean drinking water. Oh and in the rainy season all that extra water flooding into your house, along with all the sewage.

Once rainy season is over you might start playing with friends, which means playing near open fires, risking massive burns. Or maybe you’ll play on the road and get knocked over by an okada or poda poda.

Congratulations, you’ve made it to five years of age! You’re one of the lucky ones. You’re doing better than one in seven children in the country (this figure varies every time I read it from one in four to one in seven). Still you’ll probably get malaria several times a year, probably not as severely though. You’ll need to get to school, then your siblings are born (let’s hope your Mum survives those pregnancies too).

Let’s say you get uneventfully through school, and into your teenage years. But your childhood comes to an abrupt end. Here comes the next challenge: pregnancy. And so it starts again….

The Year in Numbers

So the countdown is here. I am nearly at the end of my placement. I am leaving Sierra Leone and will be back home in the UK after 18 sleeps (including the night on the plane). Here’s my year in numbers (so far – I hope I will pack in a few things yet!):

6 trips to Hamilton Beach
4 visitors from home
2 trips to Tokeh Beach
21 books (so far!)
8 visits to IMATT
3 housemates
27 medical students
1 visit to the Mercy Ship (and therefore 1 Starbucks)
2 visits from photographers/journalists
3000 – how much a Star costs at Big Brother
8000 – how much a Star costs at Mamba Point
80-100 lengths at the swimming pool (per visit)
410 – weight in grams of the smallest baby I have seen here (died aged 16 hours).
700 – weight in grams of the smallest baby I have seen survive here (still alive just now and 4 days old – so still a long, long way to go).
2 trips up Sugar Loaf Mountain (one more successful than the other!)
8 tailored dresses
2 tailored Africana outfits
2 tailored tops
3 tailored skirts
2 blood donations (so far – I’m hoping to get in another before I leave)
5 weeks with no running water
13 - highest number of people I have been in a taxi with
84 blog posts (this one included)
Countless - patients, sad memories, happy memories and new friends.

Stop Press!

A quick blog to update you on the success of the Welbodi Quiz – we raised Le4,370,000, which is just over one thousand US dollars! Hopefully also a photo attached of the quiz organising team (minus Fred who took the photo). And the answer to the question is that Juba is the capital of South Sudan (the newest country in the world).

Fun at the Beach (despite the rain….)

The day after the Quiz a group of us headed to Hamilton Beach for the night. Unfortunately it rained on and off for most of the afternoon but that didn’t stop us from enjoying the atmosphere at Samso’s (sitting under the new shelter rather than on the beach!), or stop us from swimming in the idyllic Atlantic. I had a fantastic lobster and chips for dinner, then we played some fun games including a game called “Werewolf” – a tactical game of bluffing and trust (or not trusting anyone!) where we found out which of our friends were good liars….!

I organised a hut to stay in instead of camping in case of rain. Unfortunately there was indeed a massive storm overnight. Unfortunately there was a leak in our hut. Unfortunately it was right above my bed. My mattress got quite wet – I ended up flipping it over so I could dry off a bit! (Quite why I didn’t just try to move the bed I’m not sure).

It was still raining in the morning but we had a birthday breakfast for Cat followed by a long swim (hard work swimming against that drift!) Finally the sun came out (and finally I took off my cardigan) and lunch was barracuda and chips (the fish in SL really is world class) followed by chocolate birthday cake made by Becky and Hannah.

All in all a great weekend filled with friends, food and fun!

The Welbodi Quiz

On returning from Kenema there was little time for resting as on Friday evening we held the long-awaited fundraising quiz in aid of The Welbodi Partnership (www.welbodipartnership.org) at IMATT. For those of you who haven’t heard my little crusade for Welbodi, I work with the wonderful people from Welbodi in the Children’s Hospital. They are developing paediatric post-graduate training for doctors (currently there is no postgraduate training in SL), in-service paediatric training for nursing staff (again, no specialist children’s nursing training in the country) and developing other systems within the hospital (things like medical records, electricity and running water).

While we were in Kenema, Fred, Becky and Sandra had been busily organising questions (with some cross-continental help from Andy and Banke), guest lists and raffle prizes. On Friday we headed up the hill to IMATT to do some last minute organising and sorting out the layout of the bar for the evening. We then had time for a quick swim in the rain followed by a Hot Shower (it was amazing! – thanks Jenny!) and some lengthy pondering over which of my multitude of tailored blue dresses to wear for the evening.

Guests soon started arriving and I got busy selling raffle tickets which was fun as I got to be a social butterfly speaking to people while selling the tickets. Carole was our quiz-master and we had some fun rounds including topical questions on African geography (the capital of the newest country in the world, anyone?) and a music round with song words translated into Krio.

The raffle was drawn while Fred and I marked the quiz. There were some fantastic raffle prizes – thanks to everyone who donated them. Cat decided she wouldn’t use her raffle prize of a free gym session so we auctioned it off – a great idea which ended with some very high bidding and a fierce battle between two people! And finally, we got to announce the quiz winners - congratulations to the team “4 Nations” who won by a mere half a point!

It was a brilliant evening – I will update you on how much we raise when I find out the total. Anyone can of course still donate money if you wish! Well done to the wonderful Welbodi’s for organising such a great night and thanks so much to everyone at IMATT, especially Jenny for making the evening possible.

ETATing in Kenema

Cat and I went to Kenema this week to do some training for the nursing staff on Emergency Triage and Treatment in children. We had been saying for a long time that we should arrange a visit to Susan and Dickya (two VSO nurse trainers) so we finally managed to arrange it.

We got up early Sunday morning (by early I mean 4am!) to catch the government bus to Kenema. Apart from the near-fight over seats before we set off (the bus driver told the people fighting to “shut up, we’re travelling as a family, let’s pray for a safe journey” and they all did!) it was one of the more pleasant journeys on African public transport I have over made. Individual seats, a bit of leg room, and there was only one chicken (and no goats). We made it to Kenema by lunchtime and were met by Dickya, Susan and Vasile (another VSO who is working in agriculture). After lunch and a rest we were joined by Cedric (another VSO doctor) and had a last planning session and delegation of jobs for the course.

So on Monday we started the three day course! Nurses and community health officers had come from the paediatric department, the under 5s clinic and out-patients in Kenema, along with two nurse tutors from the polytechnic and three nurses from another hospital in Pujehan. We had sessions on how to triage, recognition of essential signs and symptoms, paediatric basic life support, airway, breathing, circulation, coma, convulsions and dehydration. The most fun part of the course was doing “Skills Stations” where the participants got to practice new skills such as resuscitation, triage, vital signs and how to put in NG tubes. We used scenario-based teaching which was new to many but they picked it up very quickly. It was also great to see that many nurses suggested ways in which systems need to change within their hospitals to provide a triage system to improve paediatric care.

We passed the evenings with Susan, Dickya, Cedric and Neil (who had joined us from Pujehan after getting over his bout of malaria)playing table tennis and eating some fantastic food (a combination of Sri Lankan – as Susan’s husband is Sri Lankan - and Phillipino food, and a great spaghetti bolognese made with corned beef – tastier than you would imagine!) I got a small reminder of home too – Fatorma (the house help) has Auld Lang Syne as his ring tone!

I also did something I hadn’t done so far in Sierra Leone – as our transport back to Vasile’s house each night was an okada (motorbike)! There are no taxis or poda podas in Kenema so I no choice but to use them. (Note to my Mum - you’ll be pleased to know I borrowed Susan’s helmet and clearly have survived to tell the tale).

On the last evening we held a surprise birthday party for Susan (whose birthday is while she is home in the UK) and leaving party for Neil.

On the final day of the course we held sessions on how to implement ETAT in the participants’ respective work-places. This stimulated lively discussion and lots of good suggestions from all involved. Susan and Dickya are going to follow up the training now we are back in Freetown so I hope the momentum will continue to enable improvements in paediatric care in Kenema and Pujehan.

For the finale Dickya suggested using the word PIKIN (the Krio word for child) to stand for:
P – Participatory
I – Interesting
K – Knowledge-enriching
I – Interactive
N – Nourishing (not just intellectually but also physically with breakfast and lunch provided!)
We then pluralized it to make the word PIKINDEM (which means children) as it was time to move on from what we’ve learned by becoming:
DEVELOPED individually
EMPOWERED as a group and
MOTIVATED to make a difference.

I thought this really summed up the whole course and, along with a ceremony to give out certificates, was a great way to finish up a fun three days. Thank you so much to everyone in Kenema for your hospitality.

The Missing Photo (I hope!)

This is getting very addictive….

Time for a cheerier blog. I have been spending a lot of time visiting Mr Jalloh the tailor. I have some lovely new outfits and I am hoping there will be some photos. This is only a selection (and more currently being made)! Friday is Africana day here and everyone wears traditional outfits, like the long outfit I am wearing. One of the doctors commented that I often wear skirts I have had made here to work but that I should get a full outfit made to wear like everyone else. So I wore it to work on Friday – I think that I impressed the doctors, nurses and parents and even did the ward round in sweltering hot S-C-B-U.

How do you measure your day?

How do you measure how good, bad, successful or unsuccessful your day has been? It turns out that I now measure my day by whether I have electricity and running water, and whether (and how many) any babies or children have died.

Tuesday was possibly one of the worst days I have had here. Four babies died in S-C-B-U. Three within about half an hour of each other just after the ward round had finished and another one an hour or so later. And that was only while I was there; one had died in the early morning before I arrived and another died in the evening.

It was awful. I felt terrible. I kept questioning – what else should I have done? Should I have kept resuscitating for longer? Why did these babies die? Why all at the same time? On the same day? Why all this suffering? What else should I have done? Several nurses even said to me “Don’t look so upset Shona, it’s not your fault”. I know deep down it’s not my personal fault, but that doesn’t make me feel any better.

And if it feels like that for me, how does it feel for the nurses on the ward, who will have to keep going back to work day after day, year after year? The culture of death is different here (it’s very much part of life, and it’s always “God’s Will”) but it can’t help but affect you, watching so many children die.

And if it’s like that for health care workers, what is it like for the parents and families?

Everyone here knows the statistics of child mortality. I know that there are probably children dying in the hospital while I write this blog, while I’m asleep at night, while I’m on the beach or enjoying myself with friends. But those deaths won’t affect me in the same way, because I’m not there to witness them. And I am lucky that I am able to escape physically and mentally, that I am able to reflect on it, put it all away and move on so I can go back in the next day.

Many of my friends here have very frustrating jobs working in the slow moving Ministries of Health and Sanitation or various other organisations. I met a friend on Tuesday evening who was telling me about his unproductive day. He realised “I’m telling the wrong person.” I was glad however to escape my bad day to hear about his!

I also have a running joke with my husband about who “wins” for having the worst day. I teasingly tell him off for complaining about the bus running late or the coffee machine breaking. Clearly it’s all relative to the context and everyone is allowed to moan and to have a bad day. Clearly there are also many people who suffer greatly in the UK.

I’m sure it’s not normal to measure your day by how many children have died. That’s why I don’t mind hearing about other people’s little moans. I’m sure that when I go back to the UK I will still be impatient when I have to wait in a long queue (I can stand for ages here at the bank without batting an eyelid) or annoyed if something doesn’t go to plan. But I hope that when I am annoyed or frustrated with something trivial at home, I will be able to put those things into context. I will remember those babies and how I felt and how I imagine their families feel. I can’t imagine anything being worse than that.

(Thank you - to Fred for extricating me from S-C-B-U on Tuesday and taking me for lunch and for putting up with me not being very good company, to Becky for allowing me to vent on the way home, to Sandra for your kind words of support, to Dave and Laura for cheering me up at the beach and to Andy for virtual hugs and for reassuring me that the coffee machine is now working).

Thursday

Thursday was a bizarre day, full of contrasts. Here’s what I did:

I went to the S-C-B-U in the morning ready to start the ward round. I saw a couple of babies with one of the nurses before the entourage of medical and nursing students arrived. The patients were both very sick. S-C-B-U is bursting at the seams at the moment. The babies are literally squeezed in next to each other. One of the sickest patients arrested and died. Not much fun trying to resuscitate one moribund baby while trying to stretch across another one. If anyone ever tells me in the future that the JR NICU has no space I might scream at them. I spoke briefly with the relatives of the baby who died, and then had to carry on with the ward round. (I’m still not quite sure how I do this, and believe me, it is very strange. I always wish I could just take a few minutes to be by myself after a baby dies).

I saw a set of beautiful preterm twins (I think about 32 weeks but not certain) with their mother and both grandmothers. Twin 2 doing well, Twin 1 (the little one, about 1kg) not so well. I saw about six other patients in a space the size of a cupboard. Complete with entourage of medical and nursing students. More reviewing of patients and I finished the ward round (feeling a bit faint – it is soooo hot in S-C-B-U), and went to the lab to chase up some results (we did seven lumbar punctures on Tuesday!)They weren’t ready yet.

I spoke with one of the TFC nurses as I crossed the car park – she is a relative of Baby Number Three from last week’s blog. He died the night after I wrote my blog. I said “Oshya”.

I saw a few out-patients. I admitted one of them (try not to admit if at all possible – there’s so little space and I’m so worried they’ll get a hospital acquired infection).

I went to meet Sandra, Fred, Becky and Matt (the Welbodi team) for lunch outside. Egg sandwich today (wrapped in newspaper; usually the sandwiches are wrapped in confidential letters from some Ministry or other or research questionnaires (which have been filled in) or invoices, or children’s maths books or some other interesting thing) followed by some fried chicken as I was still hungry.

I was just finishing my chicken when my phone rang – “Dr Shona, emergency in S-C-B-U” was all I heard. Despite me telling the nurses they can call me or the medical officer if there is a problem, they have never called me before! I ran off to find that Twin 1 had arrested. We tried resuscitating but to no avail. She died. I was very sad. I’m still wondering what else I could or should have done for that baby. But I was inspired by the courage of her family, who said they now needed to concentrate on Twin 1 and thanked me for everything we had tried to do.

I saw the remaining sickest patient again. He had grade 3 hypoxic ischaemic encephalopathy and was aspirating his secretions. Not a lot I could do for him more than oxygen, IV fluids and antibiotics. Even the suction is broken. I spoke with his auntie and his father so they understood how sick he was.

In the afternoon one of the other VSO doctors Ginny had organised a party for the patients and staff in the room where ICU and ER were (they’ve moved to a new location last month). A brass band from the Ballanta Music School held a concert (their opening song was Michael Jackson’s “Heal the World” – strange choice I thought, a bit incongruous! – but they were very good). It was Rafael’s birthday so we all sung “Happy Birthday” to him. Then there was a DJ, playing all the Salonean favourites. Everyone was up dancing, enjoying themselves, nurses, doctors, patients, the little kids who live on the hospital compound. I have so many memories of being in that room, where so many children died, with so much suffering. It was a very strange feeling, dancing with my colleagues and having fun, while reflecting on all those memories. And knowing that so many families are still suffering.

I spent the afternoon going back and forth between the party and S-C-B-U, amazed at the contrast between the two. I often marvel at the contrasts in this country, between the incredible poverty and the incredible beauty of the beaches. Never have a felt it as acutely as Thursday. However, the doctors and nurses deserve to have some fun once in a while so I danced along with them.

I went to the tailor to pick up some more dresses – unfortunately he hadn’t quite finished them but we checked how they fit and I dropped off some more material to get (yet) another outfit made. I walked home as it was starting to rain.

Carole came around for a drink – we sat on the balcony looking at the beautiful view drinking Real Red Wine (courtesy of Carole) and biscuits and cheese (courtesy of Cat).

We went to Independence Beach Bar for drinks and dinner for Rafael’s birthday. It was POURING with rain and we all got drenched running from Carole’s car into the bar. I never quite dried out again. I was so cold (strange being cold in SL!) after I got wet that I had to borrow a jumper! Unfortunately the barbeque went out in the rain so we had to wait two hours for dinner – although it was worth the wait. I was still cold and wet when we got home and even wore a jumper and wrapped myself in a big towel to go to bed!

A day of contrasts indeed.

The Lab

I have got to dedicate a blog to the boys and girl who work in the lab at the hospital. We have a semi-functioning lab. And it’s got much much better in the time that I’ve been here. The list of tests we can request are as follows: haemoglobin, PCV, white blood cell count and differential, malaria rapid test and malaria smears, WIDAL (the most unspecific and insensitive test for typhoid), urinalysis and microscopy, stool microscopy, sickling test, HIV antibody test, Hepatitis B surface antigen, CSF microscopy (but only a white blood cell count and gram stain – no red cell count or culture!) and they have recently started doing protein, albumin and bilirubin.

The lab staff are also the phlebotomists (they take the children’s blood). They (usually) know the meaning of urgent - Joseph particularly is brilliant at running straight to the ward to take urgent bloods when I ask. I can request a haemoglobin and get a result back less than 30 minutes. On the other hand – a bilirubin (which neonatal SHO’s in the UK can do in a matter of minutes) takes a full day…. I’m always just a bit dubious about quality control too - I’ve never yet seen an abnormal white blood cell count!

The staff are unfailingly keen, friendly and helpful. I am usually in the lab at least once a day to chase up results and (although they don’t always find said results…) they really try hard to help me. They don’t let me speak English when I go to ask them anything, so they have taught me loads of Krio too.

To the boys and girl in the lab; thanks for your help and keep up your smiles, enthusiasm and good work!

The Challenges of Auditing in Africa…

I’ve been working on a couple of audits – one on intravenous cannula and intramuscular injection associated infections and one on prescription and administration of quinine for malaria.

It’s been an interesting process. Clearly we don’t have an electronic method of tracking the medical notes (yet). The medical records clerks give the notes a separate number once they are filed (separate from the number on the notes when the child is admitted – meaning I have had to search through every single medical record to find all the notes I wanted! I think the clerks reckon I am totally barmy. 304 out of 320 notes isn’t bad though. Especially when the electricity goes off at the hospital and you can’t see anything in the windowless room. I have never been in such a dusty medical records room, and there are occasional cockroaches which come crawling out of the notes I’m looking through….

Obviously I’ve been using my computer to go through the data – again having its challenges trying to look through notes to get information in the dark…. and somewhat annoying when the electricity goes off and the computer battery dies (thankfully I’m quite good at remembering to save everything!)

They’ve both been long and laborious but I’m finally getting close to finishing them (I hope!) Hopefully they might make a difference to practice at the hospital. I want to say a massive thanks to Mr T and Abdul in the treatment who have collected all the data for the cannula audit and are working so hard for change to cannula insertion practice.

Aid

Concern, Goal, CRS, IRC, ICRC, VSO, ODI, AGI, HPA, IFAD, Marie Stopes, Oxfam, Mercy Ships, Emergency, USAID, DfID, GIZ, UNDP, Unicef, UNFPA, UNHCR, UNEP, WHO… These are just some of the many UN agencies, NGOs and GOs (non- and governmental organisations) who have a presence in Sierra Leone. I know what most of them stand for, or at least what their logos are (emblazoned across their White Land Cruisers and Land Rovers they are ever identifiable). But what do they all actually do?

Aid in Sierra Leone is all about “capacity building” in a “post-conflict environment”. We’re past the “humanitarian disaster”. Now we focus on “empowerment”, “sustainability”, and “governance.” It’s all woolly enough that it’s difficult to actually measure the “outputs”, “goals” and “indicators” (whatever all that means).

I know a lot of people who are professional development workers. They work their way up the ladder of “volunteer”, “project development assistant”, “project manager” and “country director” attending various “workshops” along the way. All the local staff receive a daily allowance plus food and drink, to attend the workshops. I’ve been at various workshops myself. I’ve even helped to organise one.

There is a massive dependence culture in Sierra Leone. I’ve said before that there are half the number of local doctors working in the hospital compared to when I started here – is that because the Ministry of Health reduced numbers of local doctors as NGOs increase theirs? I see it on an individual level as well as societal. The nurses are constantly telling me how hard working I am. I think “yes I’m trying to show you a good work ethic, trying to help you do your job better, and not just do your work for you….”

It is often asked, “What would happen if all the NGO’s left and aid money stopped?” I expect it would be absolute chaos for a while. Thousands of children would likely die needlessly. Would it be better for Sierra Leone in the long run? I don’t know the answer.

Sometimes “implementation” of aid is questionable. There are some groups who come here for one to two weeks to “do good and save lives” as Sandra put it. There are many terrible incidences when aid has gone badly wrong; food aid being used as a political weapon, or to sustain soldiers and militia during times of war.

Who’s paying for aid? We all know that the British government are stumping up $1.3 billion for the vaccines initiative. I know many people in the UK are wondering why so much money is being spent on the developing world when there are cuts in our own NHS. Perhaps though it’s better investing in development aid than have military intervention when things go wrong? Development aid is almost certainly cheaper. I think its good value for your money. I am costing the UK taxpayer far less by being here than I will be costing them as a paediatric registrar in Oxford. Babies in the neonatal unit in the UK cost thousands of pounds a day. Vaccines cost pennies. And will save many more lives in the long run.

I believe in aid. I wouldn’t be here if I didn’t. Nor would I be quoted as saying so in various British newspapers…. But it’s healthy to have a bit of scepticism and to continue to question what we are all doing here and what we are achieving. I also believe aid is not the answer to Africa’s problems; of course Africa needs to help itself.

So why do I still believe in aid? It’s a Christian value. Moral responsibility. It’s “The Right Thing to Do”. Guilt. The wish to help others more disadvantaged than myself. Everyone is human and I believe we have a responsibility to share our wealth in order to make the world a better place. There are many charities and NGO’s which I think do an amazing job, particularly the ones who work in partnership with the government (e.g. VSO and Welbodi). So I will continue to take my bricks to go building some capacity and hold my stake to advocate for others. At least until I have to cost you more, saving babies back home in Oxford!

Ethical Questions….

In a resource poor setting, it’s one of the most difficult decisions to make. How much time should I spend with one child? There are so many sick children, not enough staff and not enough equipment or drugs. How do I (and the other staff) prioritise which children I (we) spend more time with?

I gravitate towards sicker children because that’s always what I’ve been trained to do. There comes a point though, when I have done everything within my capabilities and within the constraints of the resources. Then it becomes a bit of a waiting game. Will this child get better, or will they deteriorate despite everything we can do? And if they deteriorate to the point where they are gasping – will anything that we do make a difference to the final outcome? Or will it just prolong the inevitable? Are the medication and fluids that I am prescribing killing them just as much as their disease? We can’t monitor electrolytes, there is no potassium to add to fluids and we can’t check gentamicin levels. Will they just die during the night anyway when they are not getting monitored? (On a separate issue – is this why it can be so difficult to motivate the staff to do things at times? – do they know the child will die anyway, so why bother?)

There are many children here who would be ventilated in a (proper) PICU or neonatal unit at home. At what point do I think, nothing I can do here will make any difference –would it be kinder to this child, this family, (and very sadly, a better use of resources) to withdraw care and allow the child to die with dignity?

Yesterday morning when I went into the S-C-B-U one of the babies with presumed septicaemia had deteriorated markedly overnight. He was profoundly jaundiced and had bruising on his body. He was febrile. He had irregular respirations and occasional gasps. His heart rate was good. He was unconscious. After assessing him and checking his blood sugar (which was normal) it seemed that he had a very poor prognosis, given the limitations of our resources. His parents told the nursing staff they wanted to take him home with them. They knew he was really sick and would die quickly without his oxygen and IV dextrose. I don’t know how much longer he would have survived with it. I could understand why they wanted to take him home. His father put a thumb print to sign he was discharging his son against medical advice. They left.

How long should I keep going with resuscitation? Also when I arrived yesterday morning one of the nurses was bagging a baby (this was all going on at the same time). This baby had been admitted yesterday, with a history of meconium aspiration. His saturations were about 60% for most of yesterday. I expect he had PPHN (sorry about the medical chat – translate this as “he was very sick”). Mohammed had been bagging him for about half an hour. He was gasping only intermittently and had made no spontaneous respiratory effort in response to the resuscitation. However, his heart rate was still good. How long should we keep going, knowing that there is no ventilator, no inotropes, no nitric oxide, no ECMO? As it turned out, his pupils were fixed and dilated (i.e. he was brain dead). Mohammed and I decided, after speaking with the relatives that we should stop bagging and allow his heart to stop.

Another baby (it was a busy day!) has been admitted since Thursday. His mother died two days after he was born. She was 18 years old. To be honest I’m amazed the baby survived the weekend. He has presumed septicaemia and “birth asphyxia”. Yesterday he was really sick again. He needed a blood transfusion. His father, the poor man having already lost his girlfriend, was too underweight to donate blood. So I took him back to the blood bank to get some emergency blood (amazing what a white face and a bit of advocacy will do). The father was extremely grateful to me. The baby was still alive today. But deteriorating massively. I spent quite a bit of time going back to review him. But there are 20 something (I haven’t counted) other patients on the ward all needing attention. Five or six admissions (I lost count after a while). None of them quite as sick. Still most of them would be classed as intensive care babies in the UK. But all of them with probably a better chance of survival. What do you do?

I don’t know the answers to these questions. I try to do as much as I can given the limited resources of equipment and personnel and my own limitations in knowledge and skills. For withdrawing care or stopping resuscitation, I use my best judgement at the time; take advice from the nurses and local doctors about what is culturally appropriate. In the UK we would have more fancy tests to help us come to a decision to withdraw care, and professional guidelines aiding the ethical decisions. And I wouldn’t be making the decision by myself.

Baby number three was still alive when I left this afternoon. Despite the terrible prognosis, I haven’t given up hope for him, not yet. I won’t be surprised if he dies during the night. But miracles happen. Sometimes.

“Mi fut he swell”

I woke on Saturday morning after having a lovely night out on Friday for Banke, Theo, Alex and Dorcas’ leaving party. (I even went out dancing – shock and horror!) I pottered around the house for a while, and did some work on my audits. Then I realised there was something wrong with my left foot. It was swollen. I had pitting oedema to my mid-calf. It was surrounding an infection from a mosquito bite, where my sandal strap had been rubbing. Thankfully it wasn’t sore, just a bit uncomfortable. And I didn’t feel unwell. In the evening there was a massive downpour so I ended up walking through rivers of muddy water on my way to meet some friends for dinner (it was worth it – the steak at Madam Posset’s was amazing!). After a consultation with Dr Sandra we agreed that I should take some antibiotics for my infected foot.

Thankfully it didn’t get any worse overnight. Yesterday morning I hobbled down to Congo Cross to buy some antibiotics (yes you can buy them over the counter….) Now, there is no flucloxacillin in the country. Just cloxacillin (which isn’t even in the BNF!). But they didn’t have that in the pharmacy. Nor did they have augmentin (we don’t have augmentin in the hospital but you can get it in many pharmacies). So I settled on ampiclox (a combination of ampicillin and cloxacillin).

I walked quite a lot, although slowly, yesterday afternoon. Today “he don better”. The swelling has gone down and I am no longer hobbling. Turns out ampliclox is pretty good. One of the treatment room nurses offered to dress my wound for me (obviously not impressed at my effort!). The nurses have all said “Oshya” again and told me off for getting bitten and made sure I am sleeping under a bed net at night (I am).

(“Fut” is Krio for leg; so the title of the blog means “My leg is swollen”).

The Special Care Baby Unit

(Apologies in advance for all the medical terminology.)

I’ve now moved on from Outpatients and TFC to the Special Care Baby Unit. Confusingly known as “S-C-B-U” here, it’s a far cry from any neonatal unit I have worked in before. No ventilators, CPAP machines, vapotherm or noisy alarms going off. No blood gas machine, centrifuge, bilirubinometer, blue phototherapy lights. No SHO running around taking blood gases and TPN bloods and going to deliveries. No TPN for that matter. And no potassium to add to the fluids.

What we do have are radiant warmers, oxygen concentrators, bag and masks, NG tubes, IV fluids and antibiotics and mothers who produce the greatest quantities of expressed breast milk I have ever seen.

Most of the admissions are a product of poor or non-existent antenatal and obstetric care so it seems clear that without interventions in these areas we will never reduce neonatal mortality in Sierra Leone. The current inpatient mortality in SCBU is 27% (overall hospital mortality was 13.9% in May).

The pathology is certainly interesting; presumed septicaemia (no blood cultures so I have no idea which bugs), congenital malaria, meningitis (the most turbid looking CSF I have ever seen. It was actually pus. This baby is still alive thankfully), birth asphyxia (a term we no longer use in the UK but is used frequently here) and two cases of neonatal tetanus in the last week.

It is frustrating, knowing that most of these problems are preventable. If these babies’ mothers had received tetanus immunisations during pregnancy, had received antibiotics during labour, had presented earlier in labour to medical care or if the baby had been monitored during labour and born by assisted delivery or caesarean section when fetal distress was identified then these babies would not have the problems that they do. There is little I can do as a paediatrician for many of these babies. Prevention is much better than cure.

Its also here I notice the lack of investigations and equipment the most. Without blood cultures its hard to know how long to continue with antibiotics. I tend to play it safe and probably give them longer than necessary (thereby further contributing to antibiotic resistance…) Neonates is very equipment intensive in the UK. Most of the babies in SCBU here would be ventilated if they were in the UK. You don’t need a blood gas to tell you that. I find it frustrating because I know what can be done. But until we can do basic things well here (e.g. making sure the babies get their medications, get fed regularly, observations done and everyone has good hygiene) there would be no point in having any more advanced equipment.

I am very much enjoying the team spirit in SCBU – something I missed whilst in outpatients. Doctors, nurses, nursing and medical students all on ward rounds together; everyone learning from each other. The house officer and medical students doing lumbar punctures (surrounded by an infestation of flies – no, not the most sterile procedure you’ve ever seen. But when I arrived at ODCH no children were getting LPs at all). The nursing students watching and learning why it so important for babies to receive their antibiotics.

I learned this week that I’m going to work in the neonatal unit when I go back to Oxford. It’ll be a world away from here.

Lessons I have learned – and am still learning

I wrote this list during a time when I was feeling very down about life in Sierra Leone. You’ll be pleased to know I don’t feel down at the moment, in fact I am feeling particularly up! We’re always on a roller-coaster of emotions here. I didn’t post it at the time but it’s good to reflect now I am more positive. Everything on this list is still something I’ve learned and will continue to learn from.
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1) To be grateful for small miracles.
2) That miracles do happen. Occasionally.
3) That this is a country of unbelievable contrasts – where there are beautiful empty beaches but children die every day.
4) That you can’t win every battle.
5) That some battles are worth battling. You need to choose wisely. I’m still trying to acquire that wisdom.
6) To expect nothing, because then the reward will be greater.
7) That I can be angry. Really angry. I’m still learning how to direct that anger efficiently into something positive.
8) To always try to understand the point of view of the other person.
9) My limitations.
10) That, no matter how much time I spend in the hospital, I will never save every child in Sierra Leone.
11) That time off work is very important.
12) That support from friends is invaluable.
13) That I some means of escape, and will leave at the end of the year, but my national colleagues will not.
14) That my family, friends, and health are really really important to me.

The Journey Home

Usually I have a fairly easy (although long) journey home travelling with Sandra and chatting with her. Sometimes she is at a meeting in town so I get public transport home.

This is the journey I have made a few days this week: I leave the hospital and walk along some back roads, past children collecting water from a stand-pipe, a lady selling barbequed corn on the cob and a couple of tailors. I walk past a conglomeration of poda podas on Bombay Street narrowly avoiding falling into an open sewer as I dodge other people walking past. I turn left up Patton Street, and walk past many people selling rice, onions, tomato puree, groundnut paste, pineapples, mangoes, a few more tailors and other people sitting and chatting. Others are selling things from baskets on their heads. Some men call out to me “White girl white girl”, or “baby baby.” I stop to buy some pineapple slices as a snack. I reach the top of Patton St and turn right onto Kissy Road. I have to watch where I’m going in case there are gaps in the pavement! I walk past a health clinic, a furniture store (not a shop as such – all the furniture is out on the street). I get hissed at a few times. I stop to buy some bananas and a mango from the side of the road. Some women call me over to look at some tie-dyed dresses, and I promise I’ll be back there to look again. I constantly hear the sounds of Sierra Leonean music and people shouting out what they are selling.

I keep walking on Kissy Road, past a clothes shop, and a red Royal Mail post box (!), past more people selling fruit, avocadoes and ground nuts, past some beggars and amputees and a man who looks like he might be dead (but he’s not – I’ve seen him there a few times and he is actually just sleeping on the pavement in the middle of the day…) I reach Eastern Police Station where I stop to buy a coconut. The seller machetes off the top so I can drink the milk, then machetes it in half and scoops out the meat. Yum. So refreshing. Eastern Police and the Clocktower are at the meeting points of five roads and is one of the busiest intersections of human and vehicle traffic in Freetown. I see the police somewhat ineffectually trying to control the traffic. I cross over Kissy Road, endangering my life in the process as Okadas speed past. I walk past more street sellers and turn left off Goderich Street onto an alley I can walk up with no vehicle traffic. Past the people selling grilled chicken (it smells so good, I must try it sometime) and popcorn. Past a lady selling “kill driver” biscuits (these are like shortbread and are delicious – but no idea why they are called kill driver biscuits). A man shouts to me “white girl white girl”. He is standing on top of a building and says he “wants a few minutes of my time”. I keep walking.

I walk on up the alley, past more people selling all sorts of stuff. I walk over a bridge; either side is an open rubbish tip. I get hissed at five more times. Some other people call “Oputo” (white person). I walk over a broken pipe, pouring gallons of precious water into the street. I reach Regent Road, where the poda poda stop is. I am lucky; there is an empty poda waiting; the “apprentice” shouting “Abadeen Abadeen”. I confirm I am going to Congo Cross and jump in. So do 21 others, including 3 children. And a live chicken. I am seated in the second row – strategically near the door. I have never managed to get out of a poda in a ladylike fashion so the nearer the door the better. I say “Aftanoon” to the people seated around me. The base of the music booms out from the loudspeakers. The poda does an impressive three point turn – how they don’t hit any of the oncoming traffic I don’t know. The “apprentice” leans out the door as we start moving, collecting more customers. We get stuck in non-moving traffic on Circular Road for about twenty minutes. I am sweating profusely. People call the street sellers to the poda to buy cold water and snacks. Finally, we get going. Around some back streets. Down Campbell Street. Around St John’s roundabout. Past the Youi (?spelling) building (where the Ministry of Health and Sanitation is). We speed over Peace Bridge. So called because the UNAMSIL forces stopped the Rebels here during the war. It’s a dual carriageway and everyone speeds over it. In an overcrowded poda I always worry we will tip as we speed around the corner. Thankfully we don’t and we are on Main Motor Road. I ask the apprentice to “lef me na moks” (let me out at the mosque). I only have to squeeze past on person, rather than the normal four or five. I am still sweating profusely.

I cross the road and head up “Sewer Alley”. I say “Kushe-o” (hello) to the lovely old lady. Some kids rush up to take my hand and say hello. I duck down under the washing line as I say “Kushe-o” to a little boy we call Spiderman and the carpenters. Some children say “Sheena Sheena” to greet me (this is how many people say my name – the other pronunciation is “Sonia”). Mussa at the shop reminds me that I need to bring back two empty bottles of Star. I chat in Krio with Millicent for a few minutes. I turn the corner and wave to the people who are fixing the massive hole in our road. I open the sqeaky gate. It has taken nearly an hour and a half to go about 5km. I am home.

My Fifteen Minutes of Fame

This week I will get my fifteen minutes of fame (probably more like one by the time I’ve been edited!). The BBC were here in SL a couple of weeks ago filming with GAVI (the Global Alliance for Vaccines and Immunisations) about the new vaccines which are being introduced here. Nearly two million children die each year from vaccine-preventable illnesses. Most of these deaths occur in low-income countries. Pneumonia and diarrhoea are the two leading killers, causing nearly 40% of all childhood deaths. (All stats from the GAVI website). It is really exciting that Sierra Leone is one of the first developing countries to introduce vaccines against the most common causes of pneumonia and diarrhoea. Clearly they will make a big difference to child morbidity and mortality in SL in the long run.

Here are the terrible statistics for Sierra Leone. One in eight women dies (over their lifetime) as a result of childbirth. Sierra Leone has the world’s worst indicators for infant mortality (123 deaths per 1000 live births). One in five children dies before their fifth birthday. Sierra Leone ranks 180th out of 182 countries for overall development. There are 2 doctors per 100,000 population (230 in the UK). I know only too well that there is a drastic drastic shortage of well-trained health care workers here.

Enough statistics. Fergus Walsh (BBC health correspondent) and the film crew came on the ward round with me in TFC and chatted with some parents (slightly bizarre as I had seen some of those patients on the ward round already – which the Mums thought was so funny!) After the ward round I was interviewed about my experiences here in SL. I spoke about working with the doctors, nurses and medical students and about the patients we see, and how they are dying from preventable illnesses. I was also interviewed for some papers and had another whole load of photos taken (in addition to the VSO Photographer a few weeks ago).

So my minute of fame will be on either 10th or 13th June (not sure which!) on the BBC news, to coincide with a meeting which GAVI is holding in London on 13th June entitled “Saving Children’s Lives” with the aim of bringing together donors to fund immunisation in the world’s poorest countries.

The Sierra Leonean Cinema

Banke and I went to the cinema yesterday evening. Yes, an actual cinema, in Freetown. It has just opened. We were not quite sure what to expect. Neither of us had been to the cinema for a very long time so we had a childlike sense of excitement as we arrived at the Lagoonda Complex in Aberdeen. It reminded me of how I felt going to the cinema when I was little – there was no cinema in Shetland where I grew up so a trip to the movies was one of my highlights of going on holiday. We giggled our way inside to find the familiar smell of popcorn. Of course we had to buy some. Inside, we were seated in incredibly large and comfortable seats. There was a proper big screen. Like a real cinema. It was also incredibly cold, as I find cinemas at home. There were no trailers and no Orange advert - although they did remind us to switch off our mobile phones. Unfortunately the film (Thor) was a pirated copy so the quality was not so good. It was however a really fun evening, finished off with some drinks with others in a small local bar in Aberdeen.

P.S. While out for drinks we discussed more things with a blatant disregard for health and safety regulations:

1) People on roller-skates holding onto the back of poda podas to get pulled along.
2) People perched on the back of moving lorries only holding onto the door for balance.
3) Loads of people stuffed into the back of open trucks – often standing.
4) Poda podas up-country piled high with luggage – so high they start to lean over to one side.

Oshya

People have been saying “Oshya” to me in the last few days as I’ve not been feeling too well. Oshya (sometimes shortened to “Osh”) is a Krio term to express your concern for someone, to say you’re sorry for them, for their illness, for their loss. I think it’s a really lovely word. It’s a word which just says it all, whatever the circumstance.

I have unfortunately had to say it to many families who have lost a child. Breaking bad news is something that doctors get a lot of training on in the UK; thinking about setting, privacy, confidentiality, body language, empathy, among other things. Much of this training in communication skills stems from the fact that many complaints to the NHS in the UK are regarding problems with communication. But it’s also to do with being human.

Breaking bad news is not really part of the culture here. I often find that the mothers are left purely guessing that their child has died when the doctors and nurses move away from their child to stop resuscitating. I also find that parents sometimes don’t seem to know why their child is in hospital. Many poor mothers get berated for doing something which they probably didn’t even know they were doing wrong. I’ve found this hard to understand because I’m so used to telling parents as much information as possible about their child’s illness and treatment. It’s also been proven that the more educated a mother is, the healthier her children will be.

This lack of communication is something I’ve questioned and challenged, particularly with the medical students. How would they feel if that was their child? How would they want the doctor or nurse to speak to them? Even a simple “Oshya” goes a long way.

I communicate with the mothers as much as my Krio will allow. Communication in a different language and culture can be very difficult; subtle nuances in language can often be lost in translation. Thankfully I always have a nurse and sometimes a student or two on the ward rounds; meaning they can educate the parents on my behalf. In fact, many of them are very good at it; explaining diagnosis, treatment and prognosis. I’ll never change the whole culture but I hope that those nurses and medical students might see the benefits of explaining things to parents and continue when I’ve gone.

Thankfully I’ve started to feel better now. I’ve had ORS, chicken soup and plenty of rest. I even made it out to the tailor (more new clothes!) and the swimming pool today. However I know how grateful I was to hear that little bit of sympathy; that one short word: “Oshya”.

Red Tape

Sierra Leone can be a very frustrating country to live in. If you have seen the film Blood Diamond, they use the phrase “TIA, this is Africa”. Many people here say, “There is Africa, and then there is Sierra Leone”. But once you know how to do things and how to get things done life here is actually quite simple. Especially if you can live with uncertainties regarding your electricity and water supplies, and you don’t try to do TOO much at one time!

Sierra Leone is not generally a bureaucratic country though. Today however I was subject to my first bit of Red Tape. I was at the UN pool, and the security guards would not let me in the main gate. I was told I had to walk around to the far side of the compound and use the other gate. (I should point out that I would need to walk past the main gate again from the other side of the compound to get to the swimming pool i.e. it was all a waste of time).

It was not the extra bit of exercise I objected to. Nor was I annoyed at the security guards. They were clearly just doing what they had been told to do. What I could not understand was that I have been using that gate for the last six months. No one had objected to me using it before. No one had even told me there was a problem with me using it before. And what’s more, nobody could give me a reason for this strange rule.

The thing that annoyed me the most though – this wasn’t Sierra Leone being it’s frustrating self. This was a rule made by the United Nations. Surely, surely they should be trying to help Sierra Leone develop, not get it stuck further into Red Tape and ridiculous rules. The Salonean security guards, who I have come to know quite well over time, could all understand why I objected to this pointless exercise (they assured me that they were not expecting the President, in which case I might have understood!). Thank goodness someone has some sense. Hopefully they will talk some sense into the UN. These things are sent to try us I’m sure. It certainly tried my patience. Grrrrrrrrr.

(P.S. I wasn’t allowed out the main gate either).

Things which will never cease to amaze me

1) How women manage to change their hairdo’s so frequently – and come out of little shacks looking like a million dollars.
2) How women manage to walk along the streets and non-existent pavements in the most incredibly high heels.
3) The brilliant religious tolerance in this country – the rest of the world could really learn from the way that Christians and Muslims interact. At the beginning of meetings everyone says both Muslim prayers and the Lord’s Prayer.
4) How ants get everywhere no matter how much Dettol I wipe around on the kitchen surfaces.
5) How Saloneans can be the friendliest people you’ll ever meet but as soon as they become a waiter/tress they completely forget how to smile and be polite (the exceptions to this are at Mamba Point and Independence Beach Bar where the waiting staff are very friendly!).
6) Just how much it can rain…
7) How excited I am when the NPA (electricity) is on.
8) How little kids can carry immensely heavy jerry cans full of water on their heads.
9) Just how many NGOs there are in Sierra Leone.
10) How come eggs and rice are imported from India.
11) The shocking contrast between dead babies wrapped in lapas at the hospital and the serenity and beauty of the beaches.
12) How some children, against all the odds, get better (which is clearly why I love paediatrics, and why I am here!).

Skills I have gained – and am still gaining!

VSO’s motto I about “Sharing Skills, Changing Lives”, however I am constantly learning new skills here!

1) How to have a bucket bath and wash myself including my hair with three cups of water.
2) How to get dressed and ready for work in the dark.
3) How to blag lifts around town – all good VSOs can spot a potential lift from a mile away!
4) How to drink beer again. I think that Fred and Cat are quite proud of having got me into drinking beer for the first time since I was at Uni! For volunteers on a budget, Star beer is only Le3000 (about 50p) a bottle from small shops and local bars (Le8000 from Mamba Point!)
5) Krio. I’m by no means fluent but I can certainly get by. It’s a great language – a kind of pidgin English with a bit of French and Spanish thrown in, with its own (fairly complicated) grammar. As I keep saying when people comment on my ability to speak Krio “I de try”.
6) How to negotiate fares with taxi drivers. I’m not great at bargaining for food as I usually get my fruit and veg from the same people and they tend to give me good deals and throw in a bit extra for free. But taxi drivers – I am quite good at arguing with! (the Krio comes in handy here too!)
7) How to be incredibly patient (sometimes).
8) How to hiss to gain the attention of waiting staff in restaurants (it’s not seen as rude here, honestly! – although I still don’t like it).
9) How to avoid giving out my phone number to random strangers and turn down offers of marriage (the fact I already have a husband is a very useful excuse here).
10) Wise use of available electricity, to ensure my computer and phone don’t run out of battery.
11) Ensuring I have everything I need under my mosquito net before tucking it in – phone, torch, alarm clock, book, glasses, water.
12) How to manage a ward round complete with journalists, film crews and photopraphers….! (more on this at a later time)

A Visit to the Tailor

Having been very jealous of my friends’ gorgeous outfits for the Royal Wedding Party, I decided it was time to finally get to a tailor myself. I was given two bits of material for my birthday so went to see Mr Jalloh to get them made into a dress and a skirt (yes it’s taken me nearly six months to organise myself…!)

Two weeks ago I dropped off the material, discussed the designs and got measured. Yesterday I went to pick up my new creations and I just love them! I asked to try them on (as so many women here wander around in bras or with their boobs out I very nearly just got changed in full view of everyone in the shop but my modesty got the better of me). I was shown to the “changing room”. Marks and Spencer’s it was not. But they fit, and they are so lovely. At Le15,000 (£2.50) for the skirt and Le35,000 for the dress (just over £5 – for an exact copy of a dress I had bought from Monsoon for £60!) they are great value too. I now have lots more ideas of things I’d like to get made – I have a feeling this is going to get quite addictive!

Things in Freetown which have a blatant disregard for what we would know as health and safety regulations

1) The roadworks – massive diggers moving around with no barriers, dumping large mounds of sand everywhere, large ditches appearing meaning you have to negotiate a plank of wood to get across, large holes in the road appearing with no barriers….
2) And even though the road has been finished near our house, some of the pavement seems to have collapsed already…
3) Okadas (motorbikes) driving up the wrong side of the dual carriageway meaning that crossing the road is an accident waiting to happen if you don’t look both ways!
4) Taxis and poda podas which would never pass at MOT - with broken doors, broken windscreens, broken speedometers, the list goes on…!
5) The fact that my house has metals bars on all the windows meaning that in the case of a fire we can only get out the front door – or by jumping off the balcony (a good 20ft).
6) The maintenance guys in the hospital welding a space for a new TV in triage (why does triage need a TV?!) with no welding mask, no warning to people trying to walk past and no safety barriers – and sparks flying everywhere!
7) Thirteen people in a taxi designed for five!
8) The open fires in the alley beside our house – and children running around playing nearby.
9) The rat(s?) that run around the sewer outside the Special Care Baby Unit.
10) The open rubbish dumps and open sewers all over town.
11) Taxis driving up and down the road to Mamba Point with no working brakes – and believe me, it is a big hill!

Feelings

I was in ICU briefly today looking for some medical students and as I walked through I came across a child who had died. No one was with him. He had clearly died some time before. I called the nurses over to find out who he was. He had actually been an inpatient for more than a week and it was clear from the notes that he had been very sick for the entirety of his admission.

I hadn’t seen this boy at all before; I hadn’t had anything to do with his care. I’ve been covering TFC and out-patients for a while now so hadn’t witnessed any deaths for a little while. I was profoundly touched by his death. I am, of course, touched by all deaths here. No matter what you may think, it never gets easier.

I felt so sad for this boy, for his family. I was so sad thinking his mother would come back to see him, only to find he had died in her absence (I think she had gone to get some food). I also felt sad for the nurses and doctors who had been caring for him. I know how difficult it is when a patient you have been looking after dies.

But also I felt angry. He died in a ward full of patients, but he died alone. The nurses had not seen that he died. He died of malaria – a preventable and curable disease. I’m angry that despite many many years of research and millions of pounds spent, this little parasite is still such a big killer.

I felt frustrated. So many children die here, for multiple reasons. Plasmodium falciparum, the parasite which causes most malaria here, is a really really nasty little bug. It evades the immune system and kills quickly. The children present too late. They don’t get proper monitoring. They are lucky if they get given all their medications. There is a drastic shortage of medical staff. Up-country there is a massive shortage of basic drugs. There are no proper intensive care facilities. But it’s much much bigger than just medical reasons. There are massive political reasons, social and educational reasons. Poverty. Above all poverty. My Dad once sent me an email saying that if I could save the world from malaria I would be a bigger hero than Kate Winslet (this was peri-Titanic!) Well I can save a few children. But I am frustrated that I can’t do more.

I felt annoyed. Why did it take me walking past this child for someone to see that he had died? How long might it have been before anyone else noticed? How long before had he died? Why did this child die? Why is this world so unfair?

There is another feeling – let’s call it “Oh Salone”. Not so much a feeling, more a kind of sighing acceptance that this is the way it is, that this is the way it always will be. I saw a quote once – “The opposite of love is not hate; it is indifference”. I can just about accept what I am not able to change (and really I know I cannot change much at all) but I hope I will never become ambivalent about the future for Salone.

All my emotions and feelings are heightened here. If I feel happy I am on top of the world. If I am angry I want to shout, scream, cry and want to hit someone! I’m still trying to learn to direct my anger, frustration, and annoyance into something more positive.

This evening, my thoughts and prayers are with that little boy’s family and with the many other families in Sierra Leone and the world over who have lost a loved one today.

Selena’s Visit

At the same time as the VSO visit my great friend Selena also came to visit. Unfortunately I had to work much of the time she was here but she was able to chill out prior to her trip to Malawi (she had the most epic journey to get here – Glasgow-London-Nairobi-Accra-Lungi – and then the Pelican water taxi to Freetown – on her way to Malawi its Lungi-Accra-Nairobi-Lilongwe then the long drive to Blantyre!)

We had a very relaxing weekend with a night at Tacugama Chimp Sanctuary and a night at Hamilton Beach. We had a lovely meal at Tacugama; a rotisserie chicken (which the pesky cats tried their best to get their mitts on, and teeth into!) with stir fry veg and rice, accompanied by a couple of Star beers. It was so cool there I had to use a blanket to sleep! We had a short walk and got to see the chimps again in the morning before heading off to Hamilton. I hadn’t been there for a while and had forgotten just how good the barracuda is. We were joined by Fred, Freya, Laura, Dave, Kath, Carole, Cat, Phillin, Ziggy and Sarah at various points during the weekend and had a chilled out time reading, swimming and eating above-mentioned fish!

Thanks so much Selena for coming to see me – it wasn’t exactly a short detour on your way to Blantyre, and it was just brilliant to be able to catch up and show you a small bit of Sweet Salone!