It's chilly up north (of Sierra Leone)

I'm now waiting in a first class lounge at Euston. The ticket was pretty cheap, so I decided to upgrade. I've never been in first class before so I thought what the heck. I'm waiting for Myroslava to come for a coffee. She's a friend from Canada, met her in Uganda, who's here studying for a Masters in Public Health at the London School of Hygiene and Tropical Medicine - lucky! 

Yesterday's ferry experience certainly wasn't as bad as I'd been preparing for. The usual guys running around you, trying to get commission and tips. The truck that I was getting a lift from only just squeezed onto the ferry deck! The vehicles were packed so close, that two trucks were leaning against each other. I ditched the truck, fearing I wouldn't get to the airport in time as they had a big load of cassava flour to drop off on the way.

I had a barrage of phone calls from friends in Sierra Leone, wishing me farewell which was really nice. I expect them to be 'flashing' (giving missed calls) me on my UK number soon enough. 

Airport faff went mostly very smoothly, even when it transpired that I had overstayed in the country! Oops... my fault really. I was meant to get my passport re-stamped after a month. I'd overstayed by a month! Kinda lucky that I'd learned a bit of Krio, to the surprise of many, and had that meant I'd been put in their good books. They let me off. The lady who was going through my passport recognised me apparently. I just pretended to know her too! She asked for 'a little something' for letting me off, but I said I had nothing but 500 Leones (about 10p). 

The cold cabin on the plane helped to prepare me for the chilliness that refreshed me when I stepped off the plane this morning. Sort of welcome, but at the same time, reminding me of all the layers that I'll have to wear from now.

Adventure. All the way to the end.

I'm sat in a truck on it's way to pick up a shipment of yellow fever
vaccines at the airport. I had so much time to spare at the ferry
port, I couldn't resist trying to hitch a ride for the 15 miles to the
airport on the other side!

Tamba the driver has agreed to the lift for free because he likes
medical people, and he says it's a medical truck. Telling people
you're a student doctor gets you favours at times :) The truck's not
that medical looking. Looks more like a goat transporter or something.

Next to the ferry which we're about to drive on to is a huge rusting
hulk of an old ferry being dismantled. The harbour is full of rusting
relics, consigned to a slow watery decay. They could really do with a
ship building industry here. There's a fantastic deep water harbour.

I met a doctor just now. Private and proud. I couldn't believe some of
the shit he was coming out with! Botswana's HIV problem is due to anti
retroviral medication... What a load of crap. High prevalences in a
country that uses so much medicine that treats HIV?! Had he thought
about it, he'd have realised there were so many people with HIV
because they hadn't died yet (thanks to the medicine)! Conspiracy my
arse.

--
Sent from my mobile device

James Chan
--
e: james.chan.uk@gmail.com
t: +44 (0)7886 237 501
b: jamesonelective.blogspot.com

Last day

There are less than 24 hours until my flight leaves the ground. I hope I'm on there when it takes off.

The airport is situated across a huge river mouth from Freetown. It's 187km by road which takes about 5 hours. Bear in mind my flight takes 6 to reach Heathrow.

Options left:

• Pelican water taxi
• Last time made me feel horrendously nauseous. I've become more susceptible to motion sickness these days. 
• Too expensive at $40
• Takes an hour
• I can try to swim if it sinks
• Helicopter
• It'd be pretty cool
• Expensive at $70
• Takes less than 30 minutes
• I can't fly if it crashes
• Ferry
• Tickets start at 1000Le (20 pence)
• Danger of muggings and theft
• No lifejackets
• It's rusty
• It'll take about 2 hours, but will 2 hours for me to get to the ferry terminus
• It may or may not run on schedule

In the last few days, I've wound down the time spent in the hospital, and really concentrated on writing up my research. I'm quite happy about what I've got. I had a chance to present the findings to a meeting of health NGOs, and Amnesty International who'd just released a (locally) controversial report on maternal mortality and was met with some raised eyebrows and good questions. It was interesting insight into the NGO world - I find it so interesting!

I spent a good few hours yesterday saying bye to everyone I would miss (some not so much) in Kamakwie. Being in Freetown now really made me realise how lucky I was to be able to live in a rural community, with fresh air, and people who had time to form relationships with. I sometimes felt rude being short with people, but you just have to if you want to do a research project. People will always come knocking at your door to just come in and sit down... and watch you work, or they'd sit in relative silence.

A quick once-around the hospital made me smile. The kid in bed P15 was doing better. The 1-and-a-bit year old had come in with a fever, haemoglobin of around 5g/dL (quite low) and had developed very congested lungs at some point too. He had several convulsions on the day of admission. I made sure he got oxygen therapy (two 30 minute sessions per day), and helped him to loosen his sputum and encouraged him to cough by rolling him onto his side. After 3 days, his chest had cleared and was breathing and breastfeeding fine! Only thing was I suspect he had cerebral malaria. He was a bit rigid, and had poor head control, and had that look in his eyes. He may have ended up with a cerebral palsy and possibly epilepsy as a result of cerebral malaria. But he's alive. I saw so many children die from respiratory failure. Nobody before I encouraged it, put children on oxygen. There's one oxygen concentrator in the theatre which can be used when the generator's on so it's limited, but available. First line treatment is antibiotics and antimalarials. Frankly, I don't consider this to be a good standard even with the resources available.

I've done a lot of thinking whilst here, but not enough blogging so I'll continue to write a bit on here even though I'll be back in the UK soon... ugh, 5th year beckons. Not feeling up to it. At least I can be happy to boast I don't have to fill in the dastardly MTAS form for jobs.

Final few things before bed... I think I'll take the ferry.

Things I'll miss:

• The sound of intense downpours and thunderstorms directly overhead - awesome!
• The sound of chirruping insects at night
• New friends
• Groundnuts!
• Red soil
• Doing things by torch/candle light
• No electricity
• Bucket showers
• The handshake
• The wrist shake
• Avoiding emails
• Trying to carry things on my head

Things I won't miss:

• Black ants biting all the way up my leg
• Tripping on big rocks and roots at night
• My dodgy bed and mattress (and a bad back)
• Over genial greetings
• Having to accept food every time it's offered to you
• Expressions of disbelief/horror that I'm not religious 
• 'You're not Christian, so you're Muslim?'
• 'No'
• 'But you believe in God, right?'
• 'Err, not exactly'
• 'So what do you believe in?'
• Taking malaria prophylaxis
• Humidity

About a week to go

With a week to go until I return to Freetown, things are winding down here in Kamakwie. I've been stressing a bit about writing up my research project, and trying to find enough time to be down at the hospital. It feels like I have to be there, as there are so few (trained) people to just keep an eye on the patients!

Ramadan finished last week, culminating in the Rama Jam at the community hall. It was a bare hall, full of sweaty dancing people, lit with a single strip light, music was provided by a local DJ playing Salone dance music. I'll bring some of it back home, it's very catchy!

The end of Ramadan means the food sellers make more business during the day and can get to bed earlier. My regular 'Kukri' (cookery) lady was very happy and made a special soup to celebrate. Here, soup is sloshed over rice and is usually made with fish. I tried some of the special stuff made with various animal organs (oops). I left most of the stuff that I thought once carried stuff out of a body, and just ate the rice.

I've learned a lot about providing healthcare in a resource-poor area, and a bit of medicine too. It's been kinda nice to fall into a routine of morning ward rounds with Dr Tom, Solomon the Community Health Officer student, the occasional American nurse, and the nurses and nursing aides that work at the hospital. Ward rounds pass through the obstetrics, paeds, mens and womens wards and include a pass through the Alpha Project ward for malnourished children. Afternoon clinic starts at 2 and sees minor cases and the odd patient who we deem ill enough to admit. We get by in Krio, with Solomon doing most of the translating, sometimes needing extra interpreters to speak in some of the other local languages. It's the lack of information provided on the patients' records cards that make in confusing though. They have a funny system of having 2 sets of cards (one for inpatient, one for outpatient although some are mixed). One example of inadequate organisation of healthcare.

In the past few weeks, various people have approached me asking for support for school fees. I get the feeling that people are giving me the bags of groundnuts to sweeten me up in a way. I don't blame them for trying, but I really don't have that much to give away! I get into this problem thinking that it's not fair that only a few receive support, and it's those who are lucky enough to have contacts with foreigners and can already speak English.

I may have found something to help support though. A few nights ago, I met a few people from a local youth cooperative who have just organised themselves to run an agricultural project, and plan on other socially constructive projects. I designed a logo for them and have given some advice on budgeting, strategic planning for the future, and some generic 'how to run an organisation' type stuff that I know. They have plans to build up funds to help themselves through higher education, and to create hardship loans for members who fall ill etc. It's quite inspiring to see the local community organise itself to attempt to provide for themselves, to fill in the gaps that the state's supposed to provide - social security and employment opportunities. I set up an email account for them, it's a little strange to see people struggling to find their way around a computer keyboard, let alone use the Internet. I take it for granted that most people in the UK are computer literate and have the skills to use the Internet and get access to all that stuff out there.

Looking forward to coming back home now. I feel as though I've not really spent to much time with family! But it's straight into 5th year, and it's going to be a tough final year. If all goes well, it's less than a year to go until I start work as a doctor... uh oh.

Outamba Kilimi National Park

Last weekend I went to the Outamba Kilimi National Park with a Dutch
medical student friend, Feia, and two of the Health Unlimited field
officers, Samuel and Alusine. The park's about an hour and a half
north of Kamakwie by motorbike. We were all worried about Samuel as he
had raging malaria!

We'd hoped for hippos but everyone said that they all move away from
the river in rainy season. But the canoe ride was fun! Good work out
paddling against the strong current, and happily whiled away the time
singing row row row your boat :) Certainly not quite as fun as the
rafting on the Nile last year!

The whole tourist set up was burned by the rebels during the war. The
decaying stone ruins look reminiscent of the temples at Angkor Wat.
Not because of its architecture, but the way the nooks and crannies
were occupied by plants and green mossy stuff. The replacement tourist
huts were built using DFID (Department for International Development
from the UK), and were all partially submerged in a flash flood a few
days earlier... Uh oh.

We were the second lot of visitors in 2 months as the rainy season
makes the ferry crossing difficult and the roads are fairly jarring.
Plus, the animals all bugger off. In the dry season, one can
supposedly see hippos, elephants, chimps, all sorts of monkeys,
crocodiles, and a hell of a lot of other visiting ex pat tourists from
Freetown. We did come across monkeys at the camp who took to throwing
things down at us from the trees!

There used to be more animals according to Daio, the park ranger. Many
were killed by the rebels for bushmeat, an activity which has now
continued. The consumption of monkey meat is the best theory we have
about the origin of HIV. I wonder what other nasties await us.

--
James Chan
--
e: james.chan.uk@gmail.com
t: +44 (0)7886 237 501
b: jamesonelective.blogspot.com

A bit medic-ed out

Wowser! I’m really feeling quite burned out after this week. It’s been pretty non-stop, with 8.30 ward rounds lasting until 11.30, clinics from 2pm to 5pm, then I’m back in the evenings to keep an eye on the kids mostly. Not finding much time for blogging, finishing my research, or just relaxing. I’m finding that I’m craving a cold bottle of coke each day to get me through the day! Ugh oh…

I’m learning a lot, and there’s a lot more to learn. And not just pure medicine either. As with any patient, clinical and medical science aren’t the only toolboxes used to treat people. The social, cultural, and physical environments play a large role in the treatment of any patient, but over here, they’re very different from the UK.

I’ve seen a lot of very sick young children. 4 have died this week in the hospital. A few things I’ve picked up:

Children are generally at the bottom of the pecking order when it comes to the food. Men eat the best bits, cos they ‘work the hardest’. Malnutrition is widespread and an be very severe, making children more susceptible to disease and reducing chances of survival. This is the ‘hungry season’ when people don’t have a lot of stored food/money available, and food is expensive. Many people eat only 1 or 2 meals a day.

When sick, many patients will first try the local medicine (I haven’t managed to coin a phrase that doesn’t sound like I’m trying to mock it). This is cheaper than going to the hospital. Everything must be paid for here (thank you NHS/‘socialised medicine’). Patients’ families are generally very shy about disclosing use of the local native medicine, or ‘country medicine’. They have denied its use despite seeing the remnants of herbs smeared on the patients. This may be because healthcare staff scald them about using it, embarrass them, and adopt a very ‘told-you-so’ attitude.
So, patients are often delayed.

The management of healthcare: you can’t blame poverty for everything. I’ve seen that there can be miscommunications, mistakes, and poor organisation. There are no drug charts by the bedside, no whiteboards to give ‘at-a-glance’ views of patients, and there are very real language barriers (Krio, English [British and American], Limba, Temne, Susu, Fullah, uncommunicative). Patients’ records are basically small index cards, leaving little room for expanding on histories, and making clear procedures that have been ordered etc.

There are a lot of things that can be done that require little money, but could make a big difference in morale, efficiency and communication – all vital for safety and healthcare delivery. You can’t just throw medicines, equipment, doctors and nurses at people and hope for the best. There have to be good systems in place that can make full use of all resources for patients’ safety (first do no harm), and for effective treatment.

There are reasons why many of those seemingly straight-forward things aren’t in place. In the past, local wannabe doctors used to come to the hospital, look at drug charts/patients records, and remember how they were treated, so that they can treat patients illegally outside of the hospital. Emergency drugs are locked away, and access given only to very few people – not because they want to make life difficult for emergency patients in the middle of the night, but because they will be stolen and sold. Sometimes by healthcare staff who make a pittance and want to boost their salary.

I promise a less medicy entry next.

Hospital

I started work in the hospital on Monday, and as expected, in the ward
round was tiring in the humidity, and was tough for me to get back
into thinking medicine. After so many weeks of real medicine, I'd
forgotten most of it!

Many things made it different from a ward round in the UK. Of course,
it's still the doctor trailing his team around the patients, checking
on their latest test results and routine examinations, but with
interpreters, and what I felt was a lack of a warm bed-side manner at
times – hard due to the language barrier and sheer number of patients
to get through. Because of that, I made an extra effort to smile at
the sometimes nervous, often scared-looking patients, and greet them
good morning.

There are 5 wards: paediatrics, obstetrics, men's medical, men's
surgical, women's, and there's an extra little Alpha Project room for
malnourished kids. There's one operating theatre, a lab that can do
quite a few tests, a non-functioning X-ray machine, and certainly no
canteen facilities (patients often go for days without food due to
lack of funds or family to help prepare it). No food = poor recovery.
This is something that is often forgotten by medics I think – basics.
At 5pm, after the outpatient clinic (which is like a GP surgery), the
doctor, the student Community Health Officer (Solomon), and I were
called to see a little baby boy, CJ, who was in acute respiratory
distress. He was gasping for air, not alert and quite limp. He was
previously admitted with a haemoglobin of 2.7g/dL. A kid of his age
would be classed as anaemic if his haemoglobin was below 9.5g/dL For
those who don't know, haemoglobin is what carried oxygen around inside
red blood cells. When you don't have enough haemoglobin, we call it
anaemic. 2.7g/dL was said to be "incompatible with life" according to
the doctor. We were not sure why he was struggling to breathe, we
thought it most likely mucous from a chest infection. His lungs
sounded like they were full of water.

A is for airway

I gave him a jaw thrust to open the airway as much as possible, to
make every gasp of air as worthwhile as possible. Surprisingly, some
staff hadn't heard of a jaw thrust before.

B is for breathing

Normally, he'd be given oxygen – a lot of it – but no oxygen is
available here. No oxygen concentrator, no oxygen tanks. Oxygen is the
first thing you think of in managing any patient. We took him for
nebulised bronchodilator therapy (vapourised medicine to open his air
tubes as much as possible). There's no electricity in the wards, so we
had to do this in the lab. His oxygen saturations (the proportion of
haemoglobin in your blood carrying oxygen) had gone from 80 to 97 from
this alone.

C is for circulation

He'd been transfused with donated blood already, but no test was
called for to have his haemoglobin checked again. Even if he had 100%
saturated haemoglobin, and he only had a quarter of the normal level
of haemoglobin, he may as well have bled ¾ of his blood away – there's
just not enough oxygen going around his exhausted body.
(His post-transfusion haemoglobin wasn't checked at all.)
DEFG is for don't ever forget glucose.

Well, we forgot glucose. Actually, I'm not sure if we did or not,
because I don't think we have the equipment to test for it.
I asked the ex-pat American nurses to do some physiotherapy to clear
some of what I thought to be mucous out of his lungs. Blood started
coming out of his nose instead, and we then thought he had pulmonary
oedema. Fluid from his blood leaking into his lungs causing him to
effectively drown. Some of the expert local nurses managed to
cannulate his hand (put a tiny tube into his vein) so we could give IV
furosemide (a medicine to make his kidneys drain fluid from his body).
He pissed pretty much straight away, and was saturating at 100%.
Breathing was laboured, but seemed much better.

I agreed to come back at 7pm to give him nubulised saline treatment,
to help him breathe better with humidified air, and again at 9pm,
whilst the generator was still on.

At 7, he did a lot better, and mum was OK.

At 8, doctor check on him, said he was doing good.

At 9, I came back to find him a lot worse, mum sobbing. As babies do,
they seem fine for ages, then they suddenly everything crashes. He was
breathing faster, shallower (probably extremely acidotic), cold hands
and feet. I called the doctor to bring the equipment to check his
saturations. I did a jaw thrust for a good while, then tried to help
clear fluid out of his lungs.

He went limp in my hands. I lay him on the bed, mother started
wailing. No pulse, called for the nurse, and I started CPR.
Before the doctor arrived, he was pronounced dead at 9.09pm.
I've never had to deal with death like this before, and never done CPR
on a baby before.

I comforted the mum, but nothing I said could help her now. The family
live far away, out of phone reception, so it maybe that the mother
will have to carry him back herself.

So much more could've been done. All those things that you learn about
in medical school… but a lot of those tools aren't available.

Groundnuts

I'm a bit bored of just keeping a diary, so I’m going to start writing a bit about the small things that I see everyday, those things that, if I seen again, always conjure up memories and thoughts about a place. First up, groundnuts.

Groundnuts are everywhere. Also known as peanuts for some reason. Groundnuts are much more logical name. I wouldn’t have guessed peanuts were from the ground at all. I’d have thought them to be something to do with peas! They’re all in their shells, and they are often seen in huge piles on the earthy ground, drying in the sun, with a watchful eye on the rain clouds above. Or they’re in huge washing up bowls (a variety of colours, most likely to be Chinese in origin), on top of people’s heads. As it’s the school holidays, many children do the carrying.

They’re often seen being eaten by everyone. I think there’s a particular 'cool way' of eating them that I haven’t quite cracked yet (haha). I often see young kids standing on the road side, avoiding the motorbikes, holding up a groundnut to their mouth, cracking it open, eating the nut and spitting the shell on the floor, all in a nice quick smooth movement. You end up seeing the shells everywhere.

I fumble with the little nut, trying to crack open the shell to the nut. I either shake the nuts out into my other palm, or pick them out if they’re stubborn. Certainly a two-handed job for me.

They taste so different too! You can get them fresh. The shell smells (and tastes) like soil, and the nut somehow cool, very crunchy and very ‘planty’. Or you can get them boiled. You get a bit of the water with the nut, a bit softer, and juicier and more peanut tasting.

Groundnuts are also included in most dishes. They tend to be ground up into a paste, dryer than peanut butter, smells the same, not as sweet though, and crumblier. It’s stirred into all the sauces and soups – fantastic!

I’ll be adding them to the pumpkin soup I’ll be making in a bit ☺

Long or short sleeves?

It's been a few days since I've written. My excuse is that I toured
the district on the back of a dirtbike at the weekend, on very very
bad roads. Some sections were rocky hilly scrambles and some involved
crossing small streams! I visited a lot of the health centres with
Samuel, one of the Health Unlimited field officers and ex community
health officer. I was quite interested to see how remote and
inaccessible some villages were, and the primary healthcare centres
available to serve them. The ferry that crossed the Kabba river
stopped working when we needed to cross it on Sunday, but no
worries... Apparently motorcycles can be ferried safely across in
dugout canoes!

I finished the 18 interviews that I'd planned to do this week by lunch
time on Tuesday. Some things that I found out... Witchcraft and
strange secret societies are implicated in some childbirth
complications. These are beliefs that may have to be challenged to
further improve referral to hospitals (opposed to performing
ceremonies to rid evil).

Just had two local guys round for a cup of tea (how English of me),
and we chatted about how they and the town were affected by the war.

"Long or short sleeves?", the soon to be amputees were asked.

These guys were about 14 when they were forced to flee and hide in the
bush. First with their families, and again after the rebels allowed
the townsfolk back home (so that they could help cook and find food).
They hid for up to a month at a time, fearing forced recruitment to
take part in cross border raids in Guinea. One guy's father was a
doctor and was threatened if he did not treat the rebel wounded. Of
course, a patient's a patient, friend or foe.

I was quite disturbed to find out that the building I'm in now was
used as a house by the rebels... Strange to think of what went through
their minds as they lay in what is now my current bedroom.

It tasted like grass...

I slept in today as I've been feeling rather knackered to be honest in the past few days. I've not been doing anything strenuous as such, but I just feel tired! Not sure what it is, though I'm sure it isn't malaria (oh bugger, forgot to take my tablet today). The heat and humidity just takes it out of me. Sleeping under a mosquito net is stuffy too. You wouldn't think it at first, but it really blocks out any air movement so you just sweat...mmm

I switched rooms today, so that I've got an airier room, with more windows, a nicer bridal gown type mossie net and a desk. I have this sort of romantic image of me reading and writing by candle light at my desk. The reality will probably be waiting for this blog post to upload while trying to swat these annoying little flies that manage to get past the mesh netting on the windows.

Today was quite relaxed really. I paid the market a visit, where I had to explain to people again, that I didn't want a wife, just some chillies, dried fish and rice would do fine, thank you! I was planning on making cassava leaf stew with rice - I haven't gotten bored of the oh-so-standard dish unbelievably! This was a challenge to cook on a kerosene stove that just wouldn't behave and just created a lot of soot. I was doing this by torch light, and luckily had enough light to spot that the dried fish was disgustingly off. Most people who know me that I don't mind eating out of date stuff, but this fish was beyond all that. There was this strange mould growing inside it, and these little larvae/worms crawled out of their heads... eurgh... I think I was missing a few key ingredients as my stew tasted like grass. It looked like the clumps of grass you get on a playing field after being mown, but mixed with water. I did something very wrong.

I was privy to the local council meeting this afternoon too. It was a lot like most other councily meetings I've been too in the UK, in the sense that people were falling asleep around the table, even the chairman. It picked up though, and I found out that the town was to get a gravity driven piped-water system in December this year, with solar pumps that would help pump the water up from boreholes! There was a heated discussion about how to distribute rice from the nearest city, Makeni (roads are the next big problem after water), and they chatted about the reconstruction of some local roads (very very bad, even hard to drive with a dirtbike). They it was my turn. The whole reason why I was there, was to introduce myself and to ask them to let the townfolk know about my research project. They all sounded enthusiastic about it, and gave me their blessing.

About to settle into watching a film now, just a bit before bed I think, with the insects chirruping away outside, and the Milky Way overhead which is clearly visible, and very very beautiful.

The test interview

I felt the test interview went well. Alusine worked well as an interpreter, and it was clear that he had done this before. His familiarity with Limba meant it was quite easy, and he was quite proficient in English (I'll be paying him £30 for the week). There is still the problem with accent, but this didn’t pose too much of a problem when I transcribed the interview. The transcription of the 20 minute interview took about 1.5 hours, so for 4 interviews each day, I imagine I would have to do 5-6 hours of transcription. This may be speeded up more as I get a bit slicker.

The interviewee was a male from a village, so not quite the perspective from the town that I need, but I still got some good data. This was only a practice run so it will not be taken into consideration.

Some of the knowledge about OF appeared to be correct. He knew that prolonged labour was a cause, and also attributed poor TBA (traditional birth attendant) practices to be a cause too. This is interesting as some TBAs (traditional birth attendants) have been trained to refer quickly if the labour is prolonged. On the whole though, they remain relatively untrained, and cannot deal with big problems. I will ask a more explicit question regarding TBAs involvement in some of the factors that cause delay in women reaching hospitals.

Some of the data supported the understanding that most women are ‘divorced’. Pressure is put onto them to leave the village, and are shunned by people due to their bad odour. I wonder how this affects the children she may already have. This is not a part of my study, but may be an interesting question. He also said that the pressure to leave the village and the stress experienced by the women drove some to suicide.
Although the interviewee knew that repair was possible, he felt sorrow and sympathy. I think this is fair enough. I would also feel the same.

Asked why women still give birth at home, he answered because TBAs are in their village, so they will seek their help first. This is quite logical as a part of the referral system that has been put in place. However, I wonder how long this can continue for. This sort of referral system in the UK does not exist, where women try to give birth at home first. However, for now, this seems to be the best option, to refer to hospital only if necessary, due to resource constraints. Inadequate referral is something that is troubling. Whether TBAs refer quickly enough… it may be a matter of pride or reputation to try to deliver in the home, rather than incurring costs for the family and community to send a woman to hospital, or the peripheral health units. Through informal discussions, I have learned that PHU staff may not refer onto hospital because they will not be paid for doing the work. A system of incentives must be provided to encourage them to refer, but then there is the problem of excessive, unnecessary referral to hospital which would threaten to over-burden stretched resources.

The ambulance that has been provided by Health Unlimited to the hospital has been very useful, and has dramatically shortened travelling times. In the past, they relied on hammocks to carry women, which required many men, and would have required a lot of community organising.

Interestingly, and something which I half expected, the power to decide where to give birth does not lie with the woman. The village leader and elders may decree that all births take place with TBAs, or in the hospital. The husbands, in-laws and womans relatives may all have a hand in deciding where childbirth occurs, but when asked if the woman had any power, the interviewee answered “no”.

The answer to the last question supported what is known to be widespread across West Africa. The belief that if a woman is in prolonged labour, it may be because she and her husband had an argument, or disagreement. The husband would be called to ask his wife to ask for forgiveness. The ritual itself would not last long apparently, but still something of note.

The plan for today

Today, I will practice the interview on someone with the help of my
interpreter, Alusine. He is a Limba and speaks very good English. He
also has a knowledge of obstetric fistula since he is one of Health
Unlimited's Field Officers.

Must do laundry and figure out how to iron my shirts too. I think it's
going to be a fried cassava breakfast today!

Wild Wild West Africa

My sleep wasn’t as good as I hoped. The night was hot, and my mosquito net needed extensive repair. Duct tape worked as usual, but the holes in the net were pretty big!

The building is comfortable, there’s a dining table, a lounge area, a small kitchen, and a bathroom. There’s only 2 hours of electricity here each day, in the evenings. Running water has been broken for a few weeks now. The pump from the main town has stopped working, so water has to be fetched from the well. Francis, a local man, is paid to look after the house, and do all the other things. Thankfully, this means he fetches the water for the day, and does some cooking. I think if I give him money for ingredients he can buy it and cook it. There is a fridge that runs on kerosene, and a kerosene stove too. Somewhat seemingly out of place, there is also a fire extinguisher, and about a dozen bicycles (made in China). These bikes are destined for the community health worker volunteers.

I met with Dr Tom Asher today, with some of the nurses, and other important people from the Kamakwie Wesleyan Hospital, and other Health Unlimited staff. We chatted about my research project and when I’ll be starting clinical work.

I don’t think I’ve really mentioned what my research project is about, but here it is in a nutshell:
I want to find out what the local Limba people know and think about obstetric fistula, and what the barriers are to them seeking timely emergency obstetric care when they undergo prolonged childbirth. I’ll be conducting 18 interviews with people of the town, 9 women, 9 men. I’ll also be interviewing health staff, and maybe people who have had obstetric fistula.

To the non-medics, obstetric fistula is a problem, which occurs when the baby doesn’t come out of the mother very easily. The pressure from the baby’s head damages the tissue separating the vagina and bladder/rectum, and can create an artificial channel that does not heal. Women become constantly incontinent, isolated and ostracised from their communities. It really is life destroying. The research outcomes will better inform ways to educate women on this in the future.

In the evening I went to a village not far from here to pick up a goat, randomly! On the way back, the driver, Saidu, took me to get some palm wine! The place we went to was the chiefs house, which was a hive of activity, even in the night. People (mostly children about the age of 7) were drying locally grown tobacco leaves in a smoke room. The smoke room had rows and rows of tobacco leaves, strung up on wooden poles. It was housed a large thatched roofed building. Just under the thatched roof ‘veranda’ was a fire that was built to be very smoky, and the smoke was channelled into the room with the tobacco. The children were just stood there inhaling all this smoke in. Stanley, one of the guys hanging out there also runs the dispensary at the hospital. He spoke about the lung diseases that the children get, whilst producing this growing public health scourge, which is cigarette smoking. The other thing is the land taken up by this cash crop could be devoted to something more useful, such as rice, or cassava – but unfortunately, if this was grown, it probably wouldn’t be sufficient to sustain them through the year. I get the feeling there is a bit of a food shortage up here. The wet season is described as the hungry season because crops just aren’t ready to harvest yet. Groundnuts are always in season though, and many people head into the hills in the local gold rush. That’s another blog entry though. The palm wine when it arrived was a bit sour, and deceptively, didn’t taste as alcoholic as it probably was! I’d much rather a glass of malbec to be honest!

Arrival!

Arrived! What a road... It was like driving through a river at times! Saw 4 trucks that had broken down. 2 or 3 had overturned on the bad, slippery roads. Saw a massive cobra sliding across the road! Travel out of Kamakwie will be difficult. It's been a long time since I've felt so remote and far from everything.

I met the matron, Dr Asher, and other local staff which was nice. A bit whirlwind! Going to settle in for the night soon. Making the most of the 2 hours of electricity in the eve to charge laptop.

There'll be a bit of a moot tomorrow so I can introduce myself and share my plans. I have so much respect for those who give up so much to serve the community here, it's so remote... but quite beautiful. It reminds me of a tropical version of The Shire... No Hobbits though.

En route up north

On my way to Kamakwie now! Figured out how to use internet on phone. Car's full of food for doctor, got 2 dozen eggs on my lap. Very comfy ride though! There's air con :) No goats under the seat either!

One week in

Long time no blog! It takes discipline. Nice to know people are picking up the blog feed, and I have an official follower on Blogspot! It's a strangely nice feeling, thanks Erica!

This has to be quick as I need to get to bed. I'm heading 'up-country' to Kamakwie tomorrow morning. This is a small town up north, near the Guinean border. A lot's been happening in the past few days which is partly why I haven't written much.

Been hanging out with the two Dutch women who have come for a holiday/research project. Housemates, Sunil and Steve, managed to make it to Freetown, overland from the UK. Had more warm G&T with them. Tales of bribery, arrested drivers, barren desert landscapes, the worlds longest train in Mauritania, the two ends of which disappear into the horizon (I hope I can link a picture sometime, it looked incredible!), dodgy dealing in Guinea... They have landed a semi-free apartment in Freetown now.

Met up with other medical students working at the local childrens hospital, chatted to a local journalist about all things Sierra Leone. I couldn't believe the children's hospital hasn't had an X-ray machine for 5 years. Things are tough, and I don't pretend to understand the complexities of how things work, but it's easy to see how under-resourced the country is.

Local doctors are paid Le300,000 a month, about $75, but those employed by NGOs can receive more than 10 times that salary - $1000 a month. Not a big sum for a British doctor, but it doesn't take a genius to see that this sort of a set up in a country, distorting the employment market, really can undermine governments efforts to build an effective healthcare sector.

Oh, and I hear the lost ship has been found now. I thought I saw it on the horizon, but I don't think it was the same boat.

Right, really must go to bed now. Will post soon. I hope everyone is well.

Getting into trouble

Had a major change to research plans. The ideas that Health Unlimited and I came up with over coffee in London has proved to be too difficult. I would need a sample of 13500 people to get the sort of info we want. I doubt that anyone would stump up the money for me right now, nor can I afford about 3 years out of my life!

Ate a very expensive (£10) lobster yesterday at Lumley. The rain was horrendous too. The sky just pours on a daily basis! Nothing quite like it. At least if the water pumps are off, I can just strip and stand outside.

I spent the whole day in downtown Freetown, with the intention of getting some data from the SL Information Services/UN. It turns out that the building that they occupied is now a home for someone, and has been for the past few years. Nice of them to update their website isn't it? No wonder I couldn't get through to them on the phone. I doubt that I'm going to get the numbers of households in the chiefdoms that I'll be working in up near Kamakwie.

I also went to get my phone unlocked so I can use it as a modem with the laptop. What a palaver! Cost me about £30, and about a 6 hour wait... during which I explored the area!

So, first off, a walk down the main street, to a stroll through the market. I kept spying little nooks and crannies to get good quirky photos in. So I went and took em. I bet looked weird to most of the people. I spotted quite a high vantage point over what I discovered to be Kroo Bay. A big slum area which is literally on the mouth of a 'river'/sewage outlet. Now, I know people get tetchy when you start taking photos of them (some believe it steals your soul), so I'm careful to avoid any obvious snapping, but I was taking a photo of the slums when some old guy stops and has a go at me!

"Do you have permission?", he asked.
"Permission for what?", I replied.
"For snapping picture."
"I don't need permission, there's nobody in the photograph"
"They are peoples homes. You need permission from the Tourist Board. Would you go take a picture of State House?!"
I thought to myself, "Of course I would! Of all the tourist sites in Freetown, State House is probably high up on one's list!"
I said, "There's no sign. Who would I ask anyway? And no, I don't think I need permission from the Tourist Board!"

I walked away from him. But then I thought, maybe the Tourist Board doesn't want pictures of its slums being taken. Well, they're pretty unmissable, and people have a right to see these things. This sort of scenario happened again after I had lunch in the nursing school canteen (of all places). I was stood by a big awning that opened out to a view of the slum. The security guy stopped me and asked what I was doing, as I was pointing my camera out in the general area of the slums. I told him I was taking pictures of these cool lizards on the ground (I really was). I showed him, he saw them, believed me and he relaxed. Does it sound like people didn't want snap happy tourists taking pictures of slums?

Kroo Bay slum from the nursing school.

The controversial shot of Kroo Bay.

The lizard.

Kids by a water tap, near Kroo Bay.

Oh, and I bumped in Oli Johnson, a friend from Medsin in London. He's doing his elective here in Freetown. I'll probably catch up for a drink with him this weekend.

Ended the eve with a drink on the balcony with 2 Dutch researchers. One a lawyer, the other a nurse, both looking to see how returned refused asylum seekers have fared back in SL. It's the first project that I've heard about, but something that's very important for current advocacy efforts into ensuring asylum seekers are given fair hearings. SL is not a country where you get birth certificates, and for our governments to judge their asylum claims by asking them to prove their name with a birth certificate, or to prove that they would be tortured if they're returned is insane. Who could prove that they would be tortured, apart from having been subjected to it in the first place?

Anyway, had a nice drink. Now it's time for a shower... I stink.

Mercy Ships

I went to pay Mercy Ships a visit today. Mercy Ships is an NGO which provides maternal care to women in Sierra Leone. They have a small obstetric fistula hospital close by. They are a partner of Health Unlimited, and carries out fistula repair surgery.

For those who do not know what obstetric fistula are, I'll explain. A fistula is defined as an abnormal channel connecting two organs in the body. Obstetric fistula are a result of damage to tissues in the pelvis due to childbirth, most often obstructed labour, where a woman can be labouring for days. Fistulae can occur between the vagina and bladder or rectum, and leads to severe social, psychological and physical health problems. Incontinence is a constant problem, interfering with all aspects of life. Women are often stigmatised, ostracised, isolated from their communities, sometimes because of the smell. The causes of fistulae go beyond the mere physical. Distances from skilled birth attendants, the cost of transport and healthcare, women's lack of decision making authority, the financial dependency on their husbands, malnourishment that lead to pelvis deformities, the young age of the women/girls, and the belief that prolonged labour is a sign of infidelity, are all possible factors in play.

Terri, the manager of the facility and former midwife talked about the future programmes that they have, and are applying for grant money for. They plan to train Sierra Leonean midwives, with midwife trainers coming to volunteer from Australia and South Africa soon. This is vital if the vision of an independent, self-sustainable healthcare system is to be established in Sierra Leone. NGOs cannot, and should not, be planning to stay forever.

She showed me the wards where the women stay, and showed me the sorts of things that women learn, to reskill them if necessary to improve their opportunities. The facility also acts as a maternity unit where women can come and give birth. The operating room had 2 tables, and there was an adjoining recovery room. There was a small pathology lab, and 3 wards. It seemed very well organised, with many friendly staff. I met a few midwives, some teachers, admin staff, a surgeon, an anaesthetist. They also operate a paediatric outpatient clinic, which can currently see a daily case load of 35, sometimes up to 80+ depending on voluntary ex-pat staff who sometimes volunteer.

I'm not sure what the effect of the hospital has on the retention of health workers in the public government hospitals. Wages and working conditions may be higher than in the government health sector. Many patients will wait from the early morning, or even in overnight, in the torrential rain, to be seen at the outpatient clinic. Terri said it's because of the high quality and cheap cost of care.

Tomorrow, I will attend the 'Gladdy Gladdy', a celebration of women who have undergone successful fistula repair surgery. They will be presented with jewellery and a new outfit to return home in. I will hopefully have chance in the near future to observe some fistula repair surgery, something which is very rare in the UK due to the fantastic maternity care provided by the NHS!

For more information, please look up Mercy Ships, and the Campaign to End Fistula.

There is only one medical student training in SL

I just had a quick chat with the head of the Church in Sierra Leone. He also chairs the Inter-Religious Council in the country, currently investigating the burning of a church by Muslim youths in Kambia, back in March. A part of their mission is to prevent inter-religious violence.

I asked about Kamakwie, where I will be going to next week. It has about 150 beds, and only 1 full time doctor. Other staff are trained to carry out surgery, disturbingly. They have no medical qualifications, and are 'qualified by experience'. Another saddening fact is that there is currently only 1 medical student in the country. Even their future is uncertain as scholarship money may run out due to current economic pressures. Most Sierra Leonean doctors migrate to 'greener pastures' upon graduation. The NHS, and US healthcare services are far more lucrative.

A nauseating experience

My flight over was fine. Apart from dropping my little cheesecake on the floor. I was saving it from lunch on the plane and it fell off the seat! Anyway, I sat next to an interesting woman, Ann, who seemed very well connected, having worked and lived in Freetown sometime ago, and had written the former President's (Ernst Bai Koroma) biography. I'll try to catch up with her later this week.

The airport was small, but it worked well. The conveyor belt for the luggage was supplemented by a poor chap in the middle who had to catch the bags falling off the belt, to put them back on, and was beckoned from all sides to fetch luggage. My bag got through fine.

The next bit of the journey was not so straight-forward. Straight wasn't something that was possible on the water taxi that connected the airport and Freetown across th mouth of a river. It was a small boat, so small, it couldn't fit the passengers and their luggage together. The luggage went off on a separate boat. The boat sped along over breaking waves which meant we were launched into the air quite often, which ended up in a spine-breaking crack when the hull smashed back onto the water. I had visions of this little crack, getting bigger and bigger, until one last smash against a wave would cleave the boat into two. The Dutch medical student sat behind me didn't provide much reassurance when she commented on how flimsy the 'life jackets' were and said would grab me if we went overboard because she was a strong swimmer.

Thoughts of drowning were quickly dispelled with every churn of my gastric acid though. "Focus on the distant lights. Focus on the distant lights" It was the most nauseating 40 minutes I'd ever experienced.

Mohamed from Health Unlimited, picked me up and took me to the office where there was a room awaiting. The office is situated right next to the Vice President's house incidentally which means the local soldiers and police provide great security for the office too!

Had breakfast today, spicy fish and beans with casava and rice. Great stuff! Now I have to get on with my to-do list.

The next bit

So my time at The Lancet Student is over. Wrote a few blog entries, helped organise a competition, recorded a podcast, had a nice little chat with Richard Horton, and made some nice friends!

About to jet set off to Sierra Leone after a cheery farewell to Claire. I'm leaving with mixed feelings, I miss my family, and want to spend more time with friends. But after meeting up with Health Unlimited SL Country Director, Regina, in Brixton, I feel more motivated about the research project.

My rucksack weighs a whopping 30kg (not all my stuff) so it's going to a mission to carry!

Thanks Jamie for a great night out in Brighton too!

Going to go seek out some food and find my gate. Will write soon.

Behind the scenes... at The Lancet Student

My 10 or so weeks of doing what I want for my medical elective has begun! Medical students all over the country look forward to this point in their studies, where they can head off to exotic shores...

...sip tropical juice drinks with various lacings...

...and learn a bit of medicine in between.

My elective however, starts in a sunny, but not very far off, spacious office in Camden, London. I have a few days at The Lancet offices, writing for The Lancet Student (read my first post here). Yesterday was my first day, and I had the chance to sit in and observe the manuscript meeting - a sort of ward round for articles. Instead of doctors presenting patients to the consultant, editors and other reviewers will present papers to the Editor-in-Chief, Dr Richard Horton. A very interesting behind the scenes look at reviewing, and deciding the outcome of the many manuscripts received by The Lancet each week. The live transatlantic audio/video conference link up to the New York office didn't quite work, but that's posh technology for you! It was surprising how many papers are rejected, or sent back to authors for editing actually. I heard half of submissions don't even get peer-reviewed, and half of the ones that do, get rejected.

A few hours into getting my own desk, introduced to the other interns, free tea and coffee, I wrote my first blog post about the human rights abuses in Italy (see link above).

I found it strange at first, that the offices are in Camden, right by the canal and opposite the locks. The staff are all very friendly, no doubt helped along by the free caffeinated beverages.

This morning, I arrived to find a hot-off-the-press copy of this week's The Lancet. Richard Horton led the chat about what was in this week's issue...