[Flash 10 is required to watch video]
The women flooded into the newly opened health centre - they were happy.
The Opening Ceremony of the Mile 14 Health Centre
What a way to end our time in Kambia! Exactly four months on from our first meeting with the elders at Mile 14, we had the formal hand-over of the completed health centre to the local government at the Opening Ceremony, held on Saturday 11th June. It was a joyful day, with a huge turn out from villagers to dignitaries, with entertainment, singing, dancing and of course much speech-making. It never fails to take us by surprise how much the Sierra Leoneans love making a good speech…and with everyone wanting to show appreciation for the endeavours, 3 hours ticked by before they were all done!
With a captive audience the ceremony was a good opportunity for some basic health education and also to explain to people what the health centre would be able to deliver, to manage people expectations. There is a fantastic organization called Restless Development, and they were invited to perform short skits on the topics of hand hygiene & sanitation, the benefits of trained midwives vs. traditional birth attendants and condom use (check their site, they do great work all over the world www.restlessdevelopment.org). Clearly comedians in the making, Jane and her two male sidekicks proved that the sight of men in drag raises a big laugh all over the world! Their portrayal of the local quack demanding money for a gentle whipping and shots of gin to help encourage delivery, against the caring trained nurse offering free drugs and assistance, will stick in the minds of all those watching judging by the raucous laughter and rowdy applause.
The highlight for us was seeing children of all ages from tots to secondary school kids in their uniforms walking in and out of the building looking in all the rooms and poking their heads out of windows, along with the heart swelling singing of the delighted women who stormed into the heart of the building clapping, stamping and singing at the top of their voices filling it with joy only seconds after the official opening ribbon was cut.
This is just the start of the works required on this site. In order for it to fulfil it’s status as a Community Health Centre (CHC – the highest grade of health centre before a hospital), there are a few more structures that need to be built on site; namely staff quarters for 3 people, a well to give the CHC a protected water supply (they are currently using water brought up from the river) and an incinerator (to dispose of medical waste and needles). All this will cost an additional £10,000 which we hope to try and raise (or encourage others to raise!). For now, the centre will be able to open and commence for limited service as the villagers have offered accommodation to CHO Terena, and a rota has been drawn up amongst the villagers to regularly fetch water from the river.
We have plans in place to coordinate future fundraising efforts, so watch this space for the Mile 14 website and drop us a line if you are interested in finding out more.
Our Health Centre Getting the All Clear
May was a busy month for the building of the health centre! Six weeks since our last blog, the health centre was ready for it’s formal inspection by the Kambia District Health team, the movers and shakers who would grade the health centre in accordance with their strict criteria, and essentially give us the official thumbs up, or down.
May was sizzling, with soaring temperatures (40 degrees+) and intense humidity during the day, followed by the sweet relief of torrential rains in the evenings. It was all sweaty hands on deck as we worked to complete the building before the rainy season truly deluged and ceased proceedings, and to meet our self imposed deadline of 11th June for the opening ceremony. We raised the roof, fashioning scaffolding from old timber; puzzled over how we’d keep the bats out of the roof, a nasty scourge for every health facility in the district; dug a deep pit for the VIP latrine (stands for Ventilation Improved Pit, a neat way of keeping out the flies and smells with a craftily positioned pipe, rather than a nod to exclusivity); hand built all the wooden doors and window frames, and finally gave the place a lovely lick of paint (although Clare would have loved some consultation on the choice of colour…). All the while trying to keep a very tight lid on costs and motivating the villagers to take time out from tending their farms to chip in with the building work; somehow during our planning meetings with the elders, no one had thought of mentioning that May was the busiest month for subsistence farmers as they prepared their fields and planted crops prior to the rainy season!
Full credit has to go out to the three outstanding men we hired to do all the technical construction work; Alusine, Osman and Mohamed. Mohamed especially showed a work ethic that would put Confucius to shame; he was literally burning the midnight oil. Puzzled as to why he wanted extra kerosene and petrol, I found out he was pulling in all-nighters so he could complete all the carpentry work in time. They also did a great job of passing on their skills to the village youth, and with youth unemployment in Sierra Leone at record levels, being able to train young men in a profitable trade was a really positive spin-off from the project.
Behind the scenes, Moses and I worked the corridors of the local council and hospital administration to ensure the health centre would have staff and a fully stocked medicine cupboard. The council’s strict budget planning meant that they did not have funds to allocate to an extra health centre popping up mid way through the financial year, so it took some hefty persuading to add Mile 14 to the supply chain. I am certain our work was made easier by the good will generated from Clare’s tireless work in the paediatric ward (I am sneaking this in post Clare edit J; the chief doctor in the district proudly stated in a big meeting attended by both local and central government representatives that his volunteer paediatrician had singlehandedly significantly reduced child & infant mortality in the district). With that kind of support, getting Mile 14 on the map was relatively easy! District Sister Hawa Kallon, a small, formidable yet lovely lady (in charge of all the health facilities in the district) and Water & Sanitation Officer Mr Abdul Deen (on our side but always ready to play devil’s advocate) came out to inspect our health centre.
After a nervous few moments, as Hawa and Abdul wandered around the building, their faces broke into wide smiles. They were delighted with the building! It is large, light and airy compared to many in the district and we all toasted our success with a few generous glasses of palm wine. The sweet mildly alcoholic nectar collected from a nearby palm tree just moments before. There are a number of different categories of health centre, and they have given us the 5 star treatment, by formally calling it a Community Health Centre (one step removed form a hospital) – which means that the centre requires a CHO (community health officer) and two MCHA’s (maternal and child health aides) all of whom have considerable training, who need the broadest range of medicines and equipment available, and are able to provide significantly advanced service to their community.
We were also joined on this visit by Clare’s friend and colleague Terena Tholley, whom you may remember from previous posts; she is the wonderfully dedicated CHO who worked alongside Clare in Kambia hospital, and was coming for an unofficial nosey around. We have had the excellent news that after petitioning from both sides (hers and ours) that she is destined to be the CHO based at our health centre when it is fully up and running. It is absolutely the sweetest icing on the cake that our friend and trusted colleague will be working there, and increases our personal connection with both the centre and Terena even further!
Our excitement for the Opening Ceremony to be held on the 11th June mounted!
Clare’s trip to the Mercy Ship
I took a trip to the Mercy Ship at the beginning of June. It’s a hospital ship that specialises in surgery, and is absolutely amazing (www.mercyships.org)! I must have been up-country too long because my jaw was almost dragging along the floor with the same slackness as the families I was accompanying – it was massive! Gleaming white, moored along the dockside amidst hundreds of containers (I kept thinking that our missing nutritional supplies were probably sitting in one of them!), the rain was pelting down from heavy skies and it really seemed like some kind of haven on our arrival. The staff were friendly and welcoming… they remembered assessing one of our children on the roadside in January, and greeted her by name like an old friend. It was a lovely story for me to see through in my time here, because it had been a long road travelled to get the families to the ship.
Little Rugiatu (2 year old child with Noma) came during my first few weeks in Kambia hospital, and amidst all the early chaos and adaptation to life and medicine in SL I had no idea what I could or was supposed to do! Noma destroys the soft tissue around your face and mouth, is associated typically with measles and poor dental hygiene, is tremendously disfiguring, alienating and ultimately shortens your life span. Mercy Ships were touring the country in January-February to line up candidates for surgery on the Ship, and so the long song and dance to get our girl to the ship began!
When I arrived in Kambia, the surgeons had already been and gone, and continued to leap-frog ahead of us over a matter of weeks as we exhausted options to locate them! Our internet access was so poor at this time that we even tried speaking to a slightly dim and very shocked receptionist in the UK office of Mercy Ship (she wasn’t very helpful but very eager to try); we eventually found a contact number for the All American can-do facilitador Tracy Swope during a brief window of opportunity on the internet and she managed to arrange a roadside rendez-vous with the maxillo-facial & plastic surgeons whilst her teams were travelling to the south-east of the country. After a faltering start (the Grandmother refused to get in the car, but all the others mothers on the ward gave her food and water for the journey and she was persuaded!) It looked like we were onto a winner….
However this is Salone, and things are rarely so straightforward. Healthcare staff who accompanied the family did not pass on the essential information required for us to get the family back to the Ship for their scheduled surgery, and when pressed on the issue became aggrieved that somehow he was being insulted. After some days of posturing he came to the ward one day, had a brief discussion with the uneducated illiterate grandmother and told her she should return in February and was never seen again. Predictably for you reading this, he had not given the correct information! So they left for home with the wrong information – and when families go home here, they are virtually uncontactable.
After a few emails with the Ship we found that the correct date was May 5th, and had the unfortunate experience of having to send Rugiatu (accompanied by her father this time) home again after they arrived in February expecting to go for surgery. This family lives near Guinea, only speak Susu (putting them at a disadvantage in non-Susu speaking parts of the country like Kambia and Freetown) and were incredibly poor. It was such a triumph to get them assessed, and another triumph that they actually came back for their surgery. So it was enormously disappointing to have to send them away due to an administrative error. We waited with baited breath as the days of May slipped past… and I was convinced that they wouldn’t be back. But anything can happen here…and on the 12th of May, a week after their scheduled surgery date Rugiatu and her father arrived at the hospital!
A few emails with Mercy Ship and a newly and equally accommodating South African facilitator by the name of Joan Kotze saw us make the journey for surgery on the 30th May. A culmination of efforts for what would be life-saving (certainly life-extending anyway) surgery! There were a few touch and go moments when we got there, about whether her nutritional status was up to a big operation, but the Mercy team appreciated the difficulties that had got us all to this point and made rare exception to their rules and admitted her to the Ship for a week of therapeutic feeding prior to her new surgery date. This in itself is lucky, because the teams of surgeons are constantly changing…so to have the correct skill mix on board a month after the op-date was another mini-hurdle that could have sabotaged this tale.
I have not done this story justice, but if it seems lengthy then I have at least conveyed something of the twists and turns we have taken just to get a patient to receive the treatment she needed… You will have to forgive me, as I am eager to get things down in writing before all of this becomes a distant memory. There were so many points along the way in which this tale could have been another of the SL failures/could-have-beens (I never saw the mysterious person that went with them to the first assessment – I could have killed him, so it was lucky for him really!)…with frustrations at almost every turn (even just to persuade the hospital to let us have a vehicle to take them to Freetown was arduous), coupled with moments if pure delight (to see them arrive again at the hospital in May)… The sense of relief getting them onto the boat, meeting the truly fantastic Mercy team and being shown around the Ship was just staggering. We arrived at the ship at 8am prompt having started the 3 hour journey in the dark from Kambia, and we didn’t get the all clear for admission until 3pm, at which point I left with a sniffle and some quiet tears trickling down my cheeks in the rain! Job done!
At the time we took Rugiatu to Mercy Ship, we also managed to shoe-horn another baby onto the Ship with some persuasion; she had had some awful erosive infection encouraged by sooty “native herb” compacts that had cause her ear canal and ear drum to be eaten away down to the inner ear (anatomy beyond my memory!), ruining her hearing and disfiguring her otherwise gorgeous face; it required plastic surgery before reconstruction. They too were accepted after a day of assessment and nutritional questioning, and I had the joy of seeing her in Kambia hospital in the last few hours before I left to start my travels home; the mother had come back to show us how her daughter was getting on and to say thank you! The ear looked amazing (not at all disfiguring) and she is scheduled to go back in September for reconstruction – those surgeons are something special. She tells me that Rugiatu is recovering well from her surgery too; they have created her a small mouth, and she won’t need another operation until she is 12-13years old..
Over half way - Clare reporting from the hospital
The hospital ticks on, the wards are full, we are treating plenty of people and hopefully doing some good public relations work with the community to instil some kind of belief in ‘western’ medicine alongside the traditional. It’s interesting to reflect back at this stage, and think how far it seems we’ve come since the first horrifying ward round! The ward has some law and order, people know what they should be doing (whether they do it or not), and the nurses have some pride in their tasks within the hospital – that’s my belief anyway! Our weekly teaching afternoon with the volunteers has helped to galvanise the messages, and get everyone up to speed with what we require of them – and it always ends in competition, fun and games and sweet rewards (literally!) so it feels more optimisitic. Stacey’s arrival, along with that of Dr Ashley (a young doctor from freetown) and latterly Eli, has tipped the balance and there are 5 doctors now working in the hospital (aside from the DMO). The enthusiasm and commitment of Dr Ashley, mixed with his gentle charismatic manner and rather beautiful face means that things are getting done! We have surgical lists on Tuesdays and Thursdays, Mohamed the rotund CHO who can operate has been allowed back in the operating theatre and two doctors are doing outpatient clinics per day, whilst there are two doctors on the wards. Amazing really! Stace has found it particularly difficult to adapt to working life out here working on the adult wards for all the same reasons as I did at the beginning, but with no soother of free healthcare; but her efforts to shape-up the adult wards are now paying off, and I think the path is clearer for her now. She uses a great descriptive phrase “dying from poverty”, due to patients’ lack of money to buy drugs; it happens on a weekly basis (and in a bad week, on a daily basis), grates on the soul, and feels so unbelievably immoral. For me, money being a barrier to health care is like having one of your senses removed, all the lights going out and plunging into a lifetime in the dark remembering what it was like to see beautiful landscapes… It makes you realise what elements make up our medical practice at home – we function only with good nurses, good tests, good medicines, common language and ease of (i.e. free) access. It seems so dirty that it should come down to money…and of course, is just a horrendous paradox that the most in need are the least able to afford it. Working in a place where a young man dies in the afternoon having screamed out in pain in the morning “I’m dying! I’m dying! I can’t afford the medicine” is something that echoes in your mind at the lowest moments. (He had an intestinal perforation, likely secondary to typhoid).
For paediatrics i feel like part of my job is just pitching up everyday, and leading by example. Work hard, try what you can, care and then wait and see. When it works it is wonderful, when it doesn’t the feeling is that it’s not through lack of trying – families here (used to death) are remarkably full of thanks even when their children die or are sent home to die, and we work with what we have and make the best of a bad situation. There’s a lot of communication that takes place with actions and tones of voice, and half the mothers speak neither English, Krio or Temne, but still communicate with me one way or another, and I with them, and with their children…and they see it. And I think THAT makes a big difference in making the hospital a hospitable place to come to when you’re ill. It is not the normal way of doing things here, but then paediatricians are not normal people!
3 months in I feel like I am at peace with knowing the limitations of the system. I have accepted how it is out here; which in itself makes me feel a bit alarmed, because I shouldn’t accept it. Do you know what I mean? Obviously I have to function daily, so you simply cannot feel every heart-ache of every person on a daily basis otherwise you’d go mad. I’m not at peace with the system, cost-recovery health care, the quality of care received but I am very conscious (and this experience has clarified it even more) that I am a clinician and not a politician – to change the system, to make policy and legislate, to find a path through the bureaucracy, the endless committees and agencies involved in making the situation better in countries like Sierra Leone is essential, but not for me. I am a much smaller cog in the wheel than that!
The challenge now will be in completing what I wanted to do in the time I’ve got left in the hospital. I need to establish protocols for treatment of the commonest presentations to ensure there’s some uniformity and quality about how these kids get treated; I need to step back even further and get the local doctors onto the ward so that I can guide them, and leave a legacy of staff that are trained and comfortable to deal with paediatric cases. We need to ensure that the teaching programme that we’ve expanded continues when we’ve gone, which has been helped by getting other people involved in delivering the sessions and has been great – people are now approaching us asking to do a session here and there!
It’s been an amazing few months, and now we just have to make sure it counts in some way ;-)
[Flash 10 is required to watch video]
Spontaneous joyous singing as we laid the foundations of the health centre.
Grand Designs
We thought we’d give you a quick update of how the health centre is progressing. Three weeks into the building work and we are ready to put up the roof! Refreshingly so far things have gone really smoothly. There was the slight misunderstanding with the suspiciously high number of cement bags that were being requested, but that was all sorted out and the occasional palaver between the wives on who was the best cook. Palaver is a wonderfully evocative Krio word for having an argument, which always involves a lot of wild shouting, drama and gesticulating. On this one, not much we could do but step back and let them “make palaver”!
There is still a long way to go before the health centre will start seeing patients. At the rate we are going we will definitely have the finished building by mid-May and the dream is still for Clare, and some helpers from the hospital, to run some clinics there before we leave in mid-June. The trick now is to persuade the district council (local government) to honour their part in the project by allocating personnel (a qualified nurse; apparently there is a glut of them without placements, which we find hard to believe, but we’re assured is true) and medical equipment & supplies to the centre. We are certain they will (it looks good for the incumbent Chairman, who will claim that the numbers of health centres in his district has increased by X thanks to his great efforts), but it is just a case of when; our experience of other development projects in Kambia informs us that these things move at a frustratingly slow pace, and naturally this aspect of the process is completely out of our hands.
Projects are invariably held up because funds are not released…money is there in the council coffers, and allocated on paper…but not forthcoming in practice! Money is tantalisingly close but always just out of reach, just waiting for the elusive big men at the top to loosen their purse strings. Whether it’s the national government (who have defaulted on their payment for TB medications, so now there’s a national shortage), district council (who opened a library in Kambia, complete with electrics & computers but are not releasing the funds to pay for a generator to make use of it), the district health management team (who are given money by the district council for fuel to pay for patient transfers to Freetown, but is goes into a black hole and on the front line patients are asked to cough up the costs themselves, often prohibiting treatment, or pushing families further into poverty), or the insurance company responsible for paying the repair bills for our vehicle (excellently named Med Accident Gen Ins Co)..who apparently do not have the money available to pay the final instalment, and our fully repaired 4x4 is sitting on the lonely forecourt (it was crashed in September 2010). It’s obviously a complicated issue – but we don’t think it would be amiss to use the words incompetence and corruption in a sentence to describe the way things are! Sadly it is ordinary people who are the ones directly affected by the inertia, so used to it by now that they just shrug their shoulders and softly say that “development work is slow here”. “Ah foh do? (what can you do?)” , and so it goes.
It makes the pace and optimism of the building works in Mile 14 all the more heart-warming, in this surprising juxtaposition of having a new health centre building springing up in just 3 weeks, in spite of the context, and is certainly a testament to people power!
It’s just as well we are on schedule with building work. The photos show the rains clouds are definitely gathering in the distance, as the rainy season approaches in May/June. R: I got a taster on the way back to Kambia that day. Our motorbike picked up a puncture thanks to a stray nail on the road, 5 miles from Kambia. There was a sickeningly wobbly moment as we ground to a halt, not what I needed as this was my first go on a motorbike since my accident! Traipsing back to the next village, the sky just burst open with big fat rain drops, a very refreshing and welcoming experience after 4 months without rain!
p.s little Billy and Joel got hustled and roamed free out of the compound never to be seen again! We ate the chicken! Ah foh do!
A day in the woods for Rob
On a mission to negotiate with a local woodcutter, Moses and I took a trip into the forest, past vivid green rice fields and neat rows of bright red chilli plants to the sound of buzzing deep in the undergrowth. I naively thought there’d be some kind of processing plant with logs chucked into a saw mill to make nicely formed wooden planks, then we’d argue fiercely on price with the foreman, agree and share beaming grins and hearty handshakes and that would be that, an order placed. Not a bit of it! Hacking through elephant grass and waving cheerily to local farmers surprised to see an Oporto walking through their fields, Moses and I found our woodcutter deep in the forest. Imagine intense midday sun streaming through the forest canopy, dripping humidity, sawdust flying everywhere, the intense penetrating sound of buzzing interspersed with distant monkey calls, this was woodcutting Salone style; just two men deep in the forest, one hacking away at the undergrowth, whilst the other sawing the freshly felled trees into neat planks. The planks would then be carried out, by the local villagers each balancing a plank on their heads and walking the mile or so to the nearest road. Each plank carried would earn them 1000 leones (10p). I was fully appreciating just how much sweat and hard graft is going into this project!
