Carnivals and Christmas: Looking back on a year in Sierra Leone

The dust is settling in Freetown as the dry, cooler Harmattan winds blow off the Sahara for Christmas. Each morning you wake to a fine layer covering the surfaces in the house and the previously expansive view across the 3^rd largest natural harbour in the world is shrouded and the waters still in the hazy sunrise. By contrast Freetown is vibrant and chaotic as Christmas approaches. Each day bring a new sign for a Carnival, most recently the Nurses of Connaught Hospital Carnival – tonight Friday 18^th December – and another street is festively adorned with bunting (where does it all come from?). One older Sierra Leonian Muslim proudly told me “no one does Christmas like the Sierra Leonians…”. An exciting prospect for the next could of weeks.

As I mentioned in the last blog this is an incredibly young national, in 2010 50% were under the age of 20 and it feels like it. At night the hum of music and bars, cheers from screened football matches and noisy streets drift through the air. Our street had a carnival (street party) in November. After a relatively gentle start it was only after midnight that things really got going – big sounds systems, dancing, eating and drinking... I thought, does no one on the street mind about the noise? Then you look round and can see – the street are all here, maybe one or two houses had some older members who may be at home with earplugs  (or dancing Dom) but otherwise the whole street was young and out partying.

I feel that the conical age distribution sometimes it gives the city the feel of an impetuous, sometimes cheeky 20-something year old, brimming with vitality to go places and do things, but lacking the outlets and opportunities. And with the energy and good humour that they carry, I guess it’s easy to forget what this generation has been through, and although war and ebola come to mind, these are in equal part the symptoms and cause of their issues. Many, many more have lost family members to systemic problems of childhood disease, childbirth, HIV and accidents than the headliners.

This year has been like no other, I have no misgivings and I chose it, but there is no doubt work in Sierra Leone can be an emotional rollercoaster. Arriving to Sierra Leone in the shadow of the Ebola epidemic was harrowing, moreso to hear the stories of others from the previous months although reminders still stung you from time to time. Honestly, I still sometimes have to pinch myself when I go to work, just to remind myself its all real – the global inequalities are so gross and so tragic. At the same time, I’ve met people for whom praise and admiration is the only thing they deserve – nurses, doctors and others that I hope will be friends for life.

One of these friends was a guy named Ivan. We ran together on the hash and partied away a few evenings (and mornings..?). And, although I knew him for a few months, we became good friends and he was one of those young people who was lucky to be given a break of a beneficial sponsor through school, an opportunity he grabbed with both hands. He worked for the UN, was learning languages and was energetic and full of ideas for himself and the country. Unfortunately, the night after the Street Child Makeni Marathon, he was killed in a road accident. For his friends and family it’s a tragedy, for many of us were there when he died it’s a memory that will stick in our minds and for Sierra Leone sadly I think it’s a loss that may never be fully accounted or realized.

On the wider context, I’ve been between African countries for the last 15 months and the wider context is of business and growth in a sea of ageing and grandiose leadership dotted with islands of governance. In Tanzania happily the future seems brighter with the recently elected Magufuli showing how it’s done. And in this vein, it remains clear to me now as ever that neither I nor any expatriate colleagues will ever, or should ever aim to, make the lasting changes to a country, that is the task of its people and will always come from within. But I'm proud that,in our work at KSLP, we are trying make a space for and support those who are willing and do want to. And so I’ll finish with something that Ivan told me. In fact, as we drove up to Makeni I asked him to remind of it because I’d forgotten from the last time.

If you go somewhere for a year, you grow rice, if you go for 10 years you grow trees and if you go for 20, you grow people.

Fashpack Liberia Marathon Trials: Young, bright hopes

The first thing that strikes you watching these guys and girls race is their age – the oldest person there was 21. Sierra Leone is a young nation. The second is their tenacity – the desire to compete, win and represent Sierra Leone. Not even that, everyone you talk to wants to race at the Olympics. The third is that these guys aren’t just runners, every single one of these trialists I talked to was still studying, at school or at college – young people like this are the bright future of the nation.

Anyway enough of this, you want to know the results.

We have our prequalified athletes

Men – Idrissa Kargbo, Challey, Victor, Tejan Jalloh

Women – Aminata Kargbo, Fatmata

As we lined up on the start of the Street Child Makeni marathon, Aminata’s mother, with a tear in her eye kissed her daughter goodbye. She seemed so proud but at the same time a little terrified at the prospect of this pint-sized 16 year-old running 26.2 miles – she stormed it and won.

The qualified athletes

Male

Mohammed Bah basking in 

Mohammed Bah Kamara – this 19 year old, awaiting the results of his West African Senior School Certificate Examination (WASSCE), dominated the field to win by almost a minute

Sheku Momoh – word on the street is that this 21 year old Nursing student had gas in the tank as he happily took 2^nd place

Mustapha Kamara – the oldest in the field, our 21 year old IT wizkid shares the same dream as Sheku – a place in the Olympics

Women

Fatmata Lome – all of our girls racing for qualification were less than 18 years old, with the youngest a 13 year old from Waterloo. Fatmata stole the show today, coming home just a minute behind the pack of male athletes

Georgina Sesay – coming in just 30 seconds behind Fatmata, this 15 year old has only been racing for a year and is certainly a hope for the future

Salma Sesay – this determined 17 year old is bidding her time to enter the army – I look forward to the time when she puts the male cadets through their paces on a run!

Salma, Georgina and Fatmata best of friends off the track

Masters

Phillip Phombro – a technician and electrician at Connaught, Phillip has been running all his life. He won the >50 year old category in the trials coming in 5 minutes behind the top man. If there is this category in Liberia, he’d be a good bet to win!

There we have it – the team. Thank you for all your donations so far and we will keep you updated on their progress over the next couple of weeks. Don't forget to donate, click here. To find out more, check out the website, video or follow us on Twitter @globalfashpack

Panning for Gold in Sierra Leone

From the vantage point of my Royal Air Maroc flight, the sun rises over the Sahara to the right, which slowly melds into the Atlas mountains, both landscapes ironically minituare from the air. Maybe it is the sleep deprivation that is the Royal Air Maroc Freetown – Casablanca experience, or maybe it’s genuinely a moment of reflection of the end of the first quarter in Freetown. It’s been a long while since my last blog, for a variety of reasons, and so much has happened, which makes it even more of a challenge to encapsulate everything of the last 5 months or so; apologies for the cheesy title but I think it does fit.

The Kings Sierra Leone Partnership has changed quite a bit over the time I’ve been here, no more so than in the couple of months. Many familiar faces who saw through the tough times of Ebola with such remarkable bravery and skill have moved on and the team is reinvigorated by fresh faced and energized recruits. Those that have stayed carry on principles of a true partnership, a characteristic exemplified by the KSLP starters and is, I think, so unique to our work.

And Ebola is really the place to start; hopefully, thankfully, possibly we are coming towards the end. Lots has been said, lots is still to come. The personal losses are horrific, the effects far reaching but, once all is said and done, fingers are and will continue to be pointed and heads may roll. But was it such a surprise that such a tragedy happened in West Africa? Is it a new thing that a humanitarian health disaster has struck a developing country with such devastation?

HIV, TB, Hepatitis B – all relatively easily identified, preventable and treatable but are uncontrolled in developing countries. For HIV and Hepatitis the parallels are clearer, a previously unknown pathogen that was identified too late and the effect of which were vastly under-estimated. The ingredients that allow these communicable pathogens to spread can be easily seen in any short trip around our Connaught wards and Freetown city, they range from public understanding of disease, to public sanitation, to ward practices. One of my favourite graphs in medicine shows the number of deaths from TB since the 1800’s in the UK, it shows the dramatic effect of poverty reduction, completely dwarfing the effect of the invention antibiotics in controlling TB. As our departed Country Director, Oliver Johnson says – the Ebola epidemic has exposed the “fatal flaws” in the health system of Sierra Leone. These flaws are globally driven, they demolish the concept of health in isolation and do not recognise borders. We can and should solve the crisis for Sierra Leone’s health system, but that won’t stop the next health humanitarian crisis in another country.

At Connaught in Internal medicine we largely deal with only the tip of that iceberg, managing the sick that walk through the door. And we have really focused on just that – providing the best possible quality of care alongside our Sierra Leonean colleagues. And, at the end of this first quarter, I feel proud. We have had our highs and lows, but on the day I left I went down to the admissions ward at 5:00 pm to review the new cases and was met by the 2 house officers. “Dr Paddy, we’ve clerked all of the admissions, shall we review them?” We spent 2 hours going over the cases, discussing, weighing things in the balance and at the end I, and the team in its broadest sense – drs, nurses, patient and relatives –were left with a feeling of pride, value and satisfaction that we had done a good job, I’d go as far as saying a great job in the circumstances. And with that feeling the sad times tend to fade, maybe that’s the coping mechanism, but it is important to remind myself and to remind you, the reader, that the inequities in access to the most basic basic of health needs is the greatest tragedy, even beyond all eye-catching headlines of ebola. And we, as humanity, should not accept that. There are stories to illustrate this – they happen every day – but maybe they are best left for another day. In an echo of Andrew Harding final blog in post as BBC Africa correspondent – I am a glass half full type of person, but we should not forget the hardships of the majority.

I hope this blog can start to illustrate how very closely we, at KSLP, work with our Sierra Leonean colleagues at Connaught with the priority of treating the patient in front of us. And how, when we work, Connaught’s problems are our problems and its ups and downs are our ups and downs. Given the lack of doctors and barriers to care providing the best we can is a time consuming task and, at times, gives less opportunity to step back and work on systemic issues. Striking this is a daily balancing act but more often than not I feel the balance falls in favour of the individual patient. And I think it falls that way because of days like yesterday, when the system and the team works - the doctors apply their skills and step up to a role of patient champion, working with the nursing staff to provide good care and the patient and their family feeling satisfied and valued. Those moments of functionality and positive experience are golden. It’s a team and a process that’s been grown organically and teethed over several months but on those golden days gives the whole team the gratification of this. Our task now is to use some of this slight momentum to start solving these systemic issues as a team but, as we say in Salone “small small” – one step at a time…

Welcome to your Ebola Isolation Unit

A few people have been asking about what actually happens on the unit, so in an attempt to describe it, here’s a condensed guide to what you might expect, if you came into our unit.

In Connaught, KSLP run an isolation unit, as opposed to a Ebola treatment unit (ETU). This is essentially a screening and testing point for Ebola. Anyone that comes through the doors of the hospital passes a guy with a screening sheet and temperature gun. If you score enough symptoms you get put in a tent outside, if you are a contact or from a “hot spot” you’re streamed with a much higher index of suspicion. In general however, suspicion is high as at the moment things are concentrated on finding every single last case…

You get screened on the left and then wait in the tent on the right

If you’ve screened positive you’re now in the tent and one of us will then come out in “half PPE” (personal protective equipment) – face mask, visor, apron, gloves – to take a bit more of history, to help streamline treatment inside. No touching at this stage. You’re then admitted to the isolation unit. This is when you’d meet their first space man, “full PPE”. From the top down this is… mask +visor, full body suit, inside gloves, forearm length gloves, outside gloves and apron. We’d take you inside and if you’re vomiting or have diarrhoea place you in the “Wet” area. If not you’d go to the “Dry” area. We have started putting drips in people, so if you are unwell or can’t hold anything down then one of our Ebola Survivors (or sometimes one of the rest of us) would put a drip in you. At this point, you’d get the same treatment as every other admission – a buttock injection (intramuscular) of Ceftriaxone (antibiotic), an antimalarial, a 1.5 L bottle of rehydration solution and some paracetamol. We can give a few other things; anti-sickness, heartburn medication and sometimes if people are very confused and potentially a danger to themselves of others, some calming medication. This is a really trick one but you can imagine that its is more of a risk than in a normal ward, as you or anyone you touch may have Ebola, so we try to keep things calm and separate if we can.

As you’re being taken into the unit, we try and explain a few things. Firstly, try not to be scared by all the suits and by all the other people in the unit, some of whom may be quite unwell. The suits are just for our protection. We will keep you separated from other patients and won’t be re-using any of the same equipment. Once you are in, we’ll give you some medication (as listed above), try to drink as much as possible. If you want to use the toilet, there are two small buckets next to your bed, sorry that its not so private but I’m sure you can appreciate, we can’t have everyone using the same toilet. We will bring you breakfast, lunch and dinner. Your family can bring you food as well, but any containers they bring will have to be thrown away. On that note, all your clothes will also be thrown away at the end, we’ll give you some new ones to go home with. We can decontaminate your money, jewelry and phone. Someone will be coming in to take a blood test shortly. If it comes back positive, we will treat you for Ebola and you will be sent to one of our Ebola Treatment Centres where all the other positive patients go (ETU), if not you will be discharged either home if you’re better or into the hospital if not. Unfortunately if you’re symptoms have been around for less than 48 hrs, we’ll need to keep you to repeat your test, as early test may be negative. Finally, I’m really sorry but if none of us are here inside the unit we will need to lock the doors to your rooms. Just to warn you, the main door is quite stiff so makes a bang when we close it. We’ve had some people try to escape and I’m afraid this is potentially very dangerous for the hospital and the local area. Its a really difficult time for the whole country so please bear with us for this. If you really need something, people will be passing through frequently during the day, or otherwise please shout loudly.

Door to "Orange zone" for dressing and then "Red zone"

After this initial interaction we’ll largely leave you be, unless you are unwell when we can do whatever we are able to do, although we are slightly limited – we can’t take blood tests, or test your blood sugars, a this is too much of an infection risk. We will also come and change you if are incontinent. We’ll bring you medications (a daily bum injection of antibiotic, anti-malarials and some paracetamol), food and change your toilet buckets. All of this until you finally get the good news: Your test is negative! We (still in our space suits) take you to our shower room, and you have a final shower before being given new clothes and being picked up by another of the staff at the clean entrance. As a negative patient you get your “Negative” certificate and 10,000 (1.50) for transport home.

There is lots of stuff that goes on behind the scenes, obviously we CANNOT run out of chlorine, water or PPE, and there is a team of people dedicated to this and other logistics. On a busy 6 hr shift each person uses approximately 40 pairs of gloves and washes their hands at least 50 times per day; the decontamination process alone includes washing your hands 10 times.

Ebola isolation units, not a place for people with OCD

I guess you (as the patient) might think its all a bit overkill and even a little inhumane? And I totally see where you’re coming from on this. But, as far as I can tell, you and your family don’t. You all seem to understand the pickle of a situation the country is in and you all deal with the dehumanizing process much better than I imagine I could. So well done, thanks for doing your bit by getting checked out and congratulations on being Ebola negative!