Sharing of mission in Sierra Leone

Greetings from Sierra Leone It has been a month since I arrived here.  And yet, it seemed only yesterday when I arrived at the Lungli Airport and took the ferry to Freetown.  Since then, I have settled well in Kambia. MSF has been in Sierra Leone since 1986.  During the civil war, the organisation delivered the medical needs of the people.  A decade has passed.  Peace has been restored.  Another presidential election is set in August.  People can't help but ask MSF's presence in the country when the "emergency" phase – something MSF is well known for – has long ended. In one of its recent publications (Lessons from Pain:  Treating Sierra Leone's Endless Health Emergency, 2006), MSF Holland cited that "despite the relative political stability, the population's health status has not improved from the disastrous levels of five years ago…The healthcare system barely functions and there are huge deficits of staff and skills."  Crude mortality rate has been set at 1.8 deaths/10,000 people/day.  There is 1 surgeon for every 1,000,000 and 1 midwife for every 26,000 pregnant women. These are appalling figures… and justify my reason to go to Kambia for my third mission. The town of Kambia is in the northwestern part of Sierra Leone.  It is one of country's border towns with Guinea.  It takes 5-6 hours (depending on the road condition and the driver's skill, of course) to get here from Freetown.  It's a typical African bush – dirt roads everywhere, no electricity, water comes primarily from the river; women carrying children on their backs with a lappa (a single sheet of fabric) and football playing men.  There are signs of presence of other NGOs who have been here in the past, but at present the opoto (Krio for "foreigners") are from MSF and an organisation from Japan. MSF is currently supporting the Kambia Government Hospital and Clinics in 4 villages (namely Madina, Tombo Wala,  Mambolo and Gbonko Maria).  At the hospital, MSF is involved directly in the Laboratory, Pediatrics and Maternity Wards; and indirectly involved in the Under 5 Clinic, TB and HIV/STI (sexually transmitted infections) Clinics.  I was sent here as a Pediatrician and In-patient Department (IPD) Supervisor. The Pediatrics Ward has 65 beds.  As of writing, there are 45 admitted patients.  I was told that a couple of months back (during the rainy season), there were as much as 120 patients, with 2 – 3 patients sharing a bed.  Admissions are due to malaria, pneumonia and diarrhea.  It is noteworthy to mention though that almost all of these patients have malnutrition (Marasmus and Kwashiorkor).  Thus, aside from the medical program to treat the acute problems, there is a Nutrition Program running as well.  Treating acute problems take 3 – 5 days but with the prevalence of malnutrition, and the length of time it takes to treat it, patients are kept longer and are discharged after 6 – 8 weeks. Aside from my work at the Pediatrics Ward, I am also involved with the supervision of the local staff, stock management and act as the liason person (in the hospital) between MSF and other entities (such as the Ministry of Health and Sierra Leone Red Cross).  This is a relatively new experience for me.  In my previous missions, I was never involved in human resource or pharmacy management and did minimal representation for MSF.  And now, between the ward rounds, I make roster and training schedules and approve holidays of the staff; count pills and make a 2 week order for the IPD dispensary; talk with the hospital's District Medical Officer, Health Superintendent and Matron, and be part of the Waste Management Team; attend blood donation programs. At the Maternity Ward, MSF takes care of pregnant women who are referred from the health clinics in other villages.  These are complicated pregnancies such as compound presentations, eclampsia, obstructed labor and multiple pregnancies. I am a bit frustrated how the referral system in the country works (if there is one).  In the short time that I have been here, we have seen pregnant women who arrive in the hospital after days of labor.  As a pediatrician, it is a bit frustrating for me to see the number of stillborns – as these babies would have been born healthy if only the mothers were brought to the hospital sooner. The concern for a safe pregnancy and child delivery has been addressed by MSF.  The Maternity Waiting House, completed a few years ago, was built a few meters away from the Hospital.  In this facility, pregnant women from far villages are accommodated (for free) a few weeks before their expected delivery.  This saves them the time (which takes days on foot) to get to the hospital and that when they go into labor, their condition is managed promptly. The facility is open to all.  But in practice, the women who come to the waiting house are those referred by the health clinics supported by MSF.  The impossibility to support every health clinic in the entire district explains the number of avoidable, yet hopeless cases.  Just last week, a woman arrived in the hospital with the body of her baby delivered with the head stuck in the birth canal – after walking 3 days and 3 nights from her village. Every single day is an overwhelming experience.  It is a challenge for me, as a doctor, to handle cases (such as neonatal tetanus, cerebral malaria or a 2 year old girl who weighs 4 kilograms) I would never see and give the same treatment at home.  The options are limited in the field.  These constraints have taught me not to give up easily.  Instead, creativity has been enticed to come up with solutions and thus, still give the best possible treatment. For instance, a patient vomited after each oral intake. It turns out to be that the little girl has an obstructed esophagus following caustic soda ingestion a year ago.  At home, she would have been operated right away and have a tube placed directly to the stomach to make feeding possible.  Such procedure is not possible in Kambia, or even in Freetown. Thus, instructions were given to give small amounts of food and fluid frequently.  After being admitted in the ward for observation of the new feeding pattern, the little girl was discharged after 3 days without any episode of vomiting. On the lighter side of things, life is great in Kambia.  I consider myself very fortunate to be part of a great team.  I was a bit apprehensive to be the only man in the presence of 4 other women expatriates.  This has proven not to be a problem.  I have even begun to give them foot massages at the end of a tiring day.  The expatriates' compound is not as basic compared to the other missions I have been.  I have my own tukul (thatched roof hut).  The meals prepared by the cook are a bit exciting and are shared in the main house of the compound.  Nights are spent in the entertainment tukul where we watch DVDs and drink a bottle of cold beer together.  There is no Internet in Kambia and for this reason, some people may consider it to be one of the remotest places on earth.  It was a great surprise to find out that the area is covered by cellular phone networks.  More so, the international roaming service of my cellular network at home works here! A month has passed and four more months to go before my mission ends.  I don't mind the time that I have to stay here.  In fact, I have stopped counting.  I definitely miss home – my friends and family.  Kambia is a thousand miles away.  I know some people who are totally clueless where in the globe Sierra Leone is.  But I am really glad that I have come here. Since I started volunteering for MSF, I have gone to different places I never imagined before of going.  I am apprehensive and uncertain each time I'm at the airport, looking or waiting for the MSF national staff to pick me up.  And yet as days pass, the apprehension turns to excitement, and the uncertainty to certainty.  As I walk to the hospital in the morning, I have started to enjoy the dirt road and the locals, especially the children, who always ask, "Opoto, what is your name?" Time flies fast here in Kambia.  I started writing this letter after lunch, trying to be relaxed on a Saturday which happens to be my day off the hospital.  The rest of the team has gone to the river near our compound for a swim.  I opted to stay and finish this one.  And before I knew it, they have gone back.  Another day has ended.  I wonder what is bound to happen tomorrow…  I could hardly wait. All the best, Roy

Filipino doctor Roy Anthony COSICO joined MSF in 2006. From 2007, he worked in Kambia in Sierra Leone to provide basic health care service.