The African Big C.

At the end of long, hot day, our car was well loaded with a mixture of colleagues and students. Despite the heat and the hour, the banter was flowing in Krio and English with laughter in both. We were approaching the time for examinations and tension around a number of issues emerged frequently and humour served as a release from the tensions. From a student who is also a senior school administrator we heard a story from a previous decade and of the malpractice of a teacher who ensured that students, who should not have been able to sit for an examination, found with a little payment that there was a place available on the day that mattered . Suddenly the flood gates opened on the stories of corruption... “Did you see that story on the 80 million Leones that has gone missing from the Anti Corruption Commission?” The carload laughed in chorus and further corruption anecdotes flowed faster than the traffic. 80 million Leones is £120,000, a huge sum of money in a country where the largest denomination 10,000 Leones, is only the equivalent of 2US$, a day’s pay for a 12 hour shift on building site.

In teaching a course on Christian Leadership and Church Management, Peter finds when addressing the formation of conscience and its influence on decision making, the students are over eager to provide evidence of the existence of corruption and struggle to concentrate on its causes. It is as though their experience of injustice, accumulated during the civil war, in society and in the church, is so acute that they need to unload their anger and frustrations, before addressing any analytical thinking as to what creates corruption.

The correlation between income per capita and corruption generally indicates that those nations with the lowest levels of economic inequality perform higher in the international transparency league and demonstrate a lower level of corruption. Recently the BBC world service has chosen to explore the existence of corruption by highlighting two countries at opposite ends of the spectrum, Sweden and Somalia. In doing so, they have highlighted another aspect of cause and effect, that of war and civil conflict. Sweden is nation without a history of war in the last 200 years whilst Somalia has been in civil and international turmoil for decades and where, currently, heavily armed African Union troops are desperately trying to establish government control of the capital Mogadishu.

Corruption in varying degrees is universal and the recent decision to award the 2018 World Cup to Russia has captivated the attention of those who seek to establish transparent good governance in all aspect of life, including in football. By definition corruption is a secretive transaction and as such is difficult if not impossible to measure accurately but this does not prevent attempts being made to determine the consequences of it. In this respect civic education on the end product of corrupt practices seems more beneficial than trying to offer definitions of what it is and is not. In Freetown the roadside publicity seeks to inform the public of what public services are not being delivered as a result of corruption and as such it seeks to promote accountability for individual decisions.

Across the continent corruption is seen as a pervasive problem that creates barriers to development. Transparency International’s (TI) 2010 Corruption Perceptions Index (CPI), released in October 2010, identified Africa as the most corrupt region in the world and Sub-Saharan Africa as one of the most under-developed regions on earth. Whilst Sweden is ranked number 4, of the 178 countries surveyed, Somalia occupies the lowest position. Unfortunately six African nations rank among the 10 most corrupt countries surveyed. As Sierra Leone is ranked 134, anti corruption education and strategies is vital, nevertheless, the costs of providing such is an expenditureis an added financial burden upon the nation.

Being able to afford the funds needed for Krisi Mas is a very high individual priority. The arrival of Christmas is welcomed by Muslims and Christian alike with regular talk of ‘my Krisi Mas’, meaning a personal gift. City life becomes more intense and whilst there are no grand eye-catching public displays, the increased activity of the enormous informal commercial sector is clearly evident along the roadsides of Freetown. The arrival of the Salonean diaspora from Europe and North America for the purpose of weddings and family reunions is never stronger than in December, so that the promotion of beach side carnivals results in rapid improvements to clubs and bars in the Aberdeen area of the city.

Whilst friends and family in Europe are reporting their underfoot struggles with an early arrival of an excess of snow, the return of a cobra, apparently of the spitting variety, to the area around our house, has increased the need for us to watch our step and tread carefully through the vegetation. A cobra of any size is taken very seriously and the one that we are sighting is of considerable length so that the spraying of a little diesel fuel to the surroundings and the cutting back of some of the bush, are the recommended ways to indicate that it is not welcome.

If Janice’s English class were to be asked to give words to describe snakes, many of the words would be similar in meaning to those used to describe individuals who choose to deal dishonestly. However, she would gently remind them of the positive symbolism of the snake on the pharmacy signs around the city. Snakes are also a symbol of health, and wholeness, and this is what we celebrate as the season of Christmas draws closer. With maternal health mortality at such a high level in Sierra Leone, that Amnesty International described it as a violation of a human right, posters around the town that indicate corruption as a cause of poor health care are very pertinent. The good news is that there has been significant improvement in maternal care provision in the last 6 months. However there are still far too many Salonean mothers, who are like Mary, giving birth to a baby in the isolation of the bush, on the road hoping to get to the nearest clinic, or in the most humble of surroundings should they manage to get there, and yet each birth will be honoured as yet another blessing from God.

May your season of Christmas be a time of blessing too.

Glancing at the sky and staring at the streets

Janice has just spotted the first signs of winter visitors in the sky. Were they swifts or were they swallows, mingling with resident vultures soaring high above the city? The sight of the smaller species begs the question, are the martins, swallows and swifts constant visitors, be it the northern or southern hemisphere? Do they not have homes?

The question of homes is on the computer screen in front of Peter, as the UK government has just announced a radical package of measures allowing local authorities to offer council houses on short-term lets rather than for life. It is a measure intended to shuffle the homeless to areas outside local government limits in a bid to stop ‘their houses’ becoming a ‘poverty trap’. Not surprisingly housing charities have condemned the proposals for appearing to mount ‘a deliberate attack’ on the poorest in society. British society that it is!

Meanwhile the BBC world service radio, announces that the UN Habitat - The State of African Cities report, indicates that the size of many African cities is likely to triple in the next 30 year with 60% of all Africans living in cities . “No African government can afford to ignore the ongoing rapid urban transition taking place across the continent. Cities must become priority areas for public policies, with hugely increased investments to build adequate governance capacities, equitable services delivery, affordable housing provision and better wealth distribution,” said Joan Clos, the Executive Director of UN-HABITAT.

Known as “The push and the pull factor” in rapid urbanisation in Africa, the effect is clearly seen across Freetown. Salone’s civil war exercised a push that created a huge demographic growth in the capital and with it a massive urban proliferation, a steep economic inequality and widespread human misery which persists today. The pull effect is that individual economic progress is perceived to be available in the big city where options and opportunities are assumed to be greater than in rural areas. Economic growth is most evident in the mining sector, beyond the capital, but the development that includes urban industrialisation with job creation and higher productivity is not evident . If it were, such progress would provide the basis of the pursuit of good governance, proper housing and basic services for all. Meanwhile the number of informal settlements continues to increase both along the shoreline of Aberdeen Creek, Kroo Bay and up the hillsides of Dwarzak and New England. However it is in the East of the city where in 1999, the invasion of rebels caused the destruction of about 6,000 homes in the areas of Kissy, Wellington, Calaba Town, and Allen Town.

One of our colleagues, after completing his days teaching, has never been swift to make his way home eastwards from the college in the centre of the city. To get home, he faces a tough task. There are choices, be it on over saturated public transport (mini-buses) where the competition for even space and not a seat is keen and at times aggressive, or a life threatening journey on the back of a motorbike, or alternatively on foot, with the tens of thousands who choose to walk along the major highway, the Kissy Road, all forms making such journey demanding and problematic. Of late his procrastination and delaying tactics have been even more exaggerated, as he and his family are living under the threat of eviction from a home that is without running water or electricity and for which he pays the owner £25 per month, 25% of his basic teaching salary. The imminent removal comes as result of his protesting at the 100% increase in rent. Explaining the options available, he cites the working of the city housing rent tribunal to which he can appeal and be heard by under-paid public servants who at best would delay the demand for increased rent and at worse be tempted to take the offer of financial support (from the landlord) for urgently needed domestic expenses of their own and rule against the tenant.

A driver, of the Methodist Church connexional office, and his family have just become our new neighbours, living in temporary accommodation . All six members of his family, along with several other families, were forcibly removed from a compound in the heart of the city by bailiffs, supported by police officers. The event attracted national press coverage for a brutal attack on property and provocation of violence but despite the evident injustice no re-instatements have since followed.

An east African catholic theologian Richard Rwiza writes that whilst the urban poor are “the least economically advantaged, the least socially involved and the hardest hit by the housing problem, they are paradoxically the least institutionally assisted people of the urban area”. And as our colleagues, (neither of them being abjectly poor) would testify, it is the poor who can least expect the support of judicial institutions like the courts, the police station, or indeed the health and education sectors.

It would be hard to imagine the Minister for Land, Country Planning and the Environment, in Sierra Leone, Dr Dennis Sondy, quoting the words of David Orr, the chief executive of the National Housing Federation in the UK, who said: “People need the stability and security of a safe home."

However, there has been some recognition made of the dire problems of housing related issues. Some 750,000 residents of slum communities across the Freetown municipality will soon benefit from improved water, sanitation and hygiene conditions through the intervention of the Urban WASH Consortium programme initiated by five international non-governmental organisations operating in the country. Speaking at the official launch of the programme, board chairman Emmanuel Gaima - who doubles as country director of Oxfam - said the consortium was formed to complement government's effort in attaining the millennium development goals (MDGs). "We cannot solve all the problems that have to do with sanitation in this country. 750,000 beneficiaries will be targeted for the next 3 to 5 years of the programme. We will holistically focus on water, sanitation and prolific health program," he said. According to the Oxfam country director, the initiative intends to reduce the rate of water, sanitation and hygiene diseases by supporting and working with the government, adding that the goal of the programme was to improve the health status of selected vulnerable communities in the urban area of the city.

Head of country office DFID, Dominic Oneill, described the initiative as very important as the burden of disease, due to poor water and sanitation, was very huge. He said the long term strategy to ensure the success of the programme should be through national funding, adding that Sierra Leone has the lowest revenue base in sub-Saharan Africa.

However the housing needs of our colleagues and their families continue, but they do not have the same kind of choices as the swift, swallows and martins. Their home is Salone.

The Need for Church Unity.

With the closing of the rainy season, nocturnal activity is on the increase once again, in Freetown. It comes in many forms and is very audible and not always melodic. It would appear that the dry season is revival season. Even as dawn breaks, the preachers’ amplified exhortations and alleluias can be heard closing an all night vigil in any one of the many churches and charismatic movements that exist in our neighbourhood. It is unlikely that a recent newspaper article on the subject of “church unity” is an issue for them.

Articles and stories that appear in Salone’s newspaper are habitually picked from the internet and the author’s name and the context from which they are writing never appear. This happens to be the case in the Awoko newspaper’s article “the need for church unity”, so that it is legitimate to ask, whose need, which church and what kind of unity is being referred to and where? The article makes no reference to inter-denominational relationships or ecumenism or mission so that it would be appropriate to ask what kind of church is being envisaged. Besides, it is a question any mission partner, church worker or member should be asking in Salone today.

Our own involvement in ecumenism was nurtured as mission partners with the United Church ofinvariably involved a host of denominations including Anglicans, Lutherans, Roman Catholics, Seventh Day Adventists as well the Presbyterian and Congregationalist who along with Methodists made up the United Church of PNG and Solomon Islands. Ecumenism is never more vibrant than when it is expressed in missional activity, be it by denominations or collaborative agencies.

In our current appointments, ecumenical endeavour lies at the heart of the college’s mission statement. The churches, movements and ministries from which the students are drawn are richly varied in both their histories and theology. However, they are but a segment of what can be seen in Freetown , as a manifestation of Christian based endeavour and purpose.

The library of Westhill College in The University of Birmingham includes a room dedicated to the work of Harold Turner, whose pioneering enquiry into New Religious Movements spanned decades. His work produced a wide ranging examination, which challenged long held assumptions, as to what was and what was not organised Christian religion. We met Harold very briefly when he was researching “cargo cult movements” in PNG and we shared our superficial understanding of the ‘millennium movement’, in our area of the Baining Mountains of East New Britain. Melki, its leader, was a quiet, rather shy man, but possessed a following with Uramat speaking Bainings, which frequently assembled in specific locations often close to burial sites and performed rites and military styled ritualistic acts which created a serious disquiet among local church leaders.

Known popularly as “cargo cults”, because of the anticipation of material wealth, a common feature of all millennium movements, these movements were evident in several locations across the whole of the country. At times the followers of the cargo cults were numbered in their thousands, in Melki’s case, it was but a few hundred, but like all such movements, they anticipated a day of rich material blessings to arrive in a given location and often on a given day. For Melki, the date was undetermined, but the nearby Rabaul harbour was the point at which riches, sent by departed ancestors, were to arrive at.

The transferability of this experience has become evident during our first year in Freetown. Small and mega gatherings, inspired by church and movement leaders from various parts of West Africa, have been a common feature of religious life. They are usual widely publicised with the invitation to allow “your gates to be opened” so that God’s riches may enter or for “an encounter with divine blessings”.

The phenomena of churches mushrooming on the gospel of prosperity are not confined to Salone or even West Africa, they are a universal aspect of the religious landscape in any nation, but they may well flourish better in tropical climates. It was reassuring to find that the link we have begun to make between the Melanesian “cargo cults” and the prosperity churches has been covered recently by eminent academics in sociology of religion, some of it in response to a short film made in Ghana, “Prosperity Gospel, Behind the Scenes”.

It appears that the holy seal of approval of lust, greed, and consumerism is granted by Neo-Pentecostal church leaders, who organise networks, coalitions and movements, to declare prosperity and material wellbeing to individuals, families, with a demonstration of resources that are naturally designed to impress. Even the names of the organisation alone are intriguing , “Church of the End Time Army of God”, “Battle Axe Ministries”, “Winners Chapel” and “Let My Gate be Open”.

As observant students of new religious movements, we went to the national stadium recently, to witness the first of a two night mega event of “empowerment”. A nearly half full stadium was still growing in numbers, vitality and anticipation as we seated ourselves among people at least a generation younger. As with churches across the city, women were in the majority, but the average age was younger than that which we would meet on a Sunday morning and we were greeted by a few people we knew. Responsive and willing to provide loud “alleluias” when prompted, the congregation was also eager to buy the white handkerchiefs bearing the image of the founding Bishop, ready to be waved at appropriate moments. They were also equally willing to wave the 1, 2, 5 and 10,000 Leone notes (2US$) in the air, before depositing them in large plastic bags to be tied tight and hurled over the perimeter fence onto the running track and collected by the uniformed stewards.

Emotional expression was at times exuberant but there were also moments of stillness, deep concentration and quiet reflective singing too. A choir item, led by a group who were surprisingly under-amplified for a congregation of 8,000, provided the entry of The Apostle who arrived in a cavalcade of top of the range 4x4 vehicles and a large squad of military styled “security men”, who positioned themselves across the football pitch. The presence of the Apostle/ Bishop caused one or two women’s legs to give way in a show of euphoria, but it was but a momentary phenomena and which passed without exploitation by the event leader.

In his teaching the Bishop made reference to several mission imperatives, that we could also say alleluia to. Included were poverty reduction, the creation of youth employment as well as the elimination of illiteracy and infant mortality. Frequent reference was made to being empowered to use the solution of faith. It was faith alone that would provide the material betterment to eliminate societal sickness.

When staying with Fr Pat Rasmussin, in December 1972, we discussed at length the impact of the cargo cult that had recently centred on Mt Turu, which lay within his area of work and service, in The East Sepik Province. The movement was made up of some 30,000 people, some of whom had abandoned subsistence farming in anticipation of the wealth that would emanate from the removal of a concrete obelisk, a trigo-metrical point on the summit of Mount Turu. The offending object was uprooted and the people duly returned to their villages and the anticipated social unrest from unfulfilled expectation did not arise.

The application of logical thinking, associated with the principles of the enlightenment, was considered to be of no assistance in trying to comprehend this particular millennium movement. And perhaps, despite all the automotive hardware of 21^st century engineering and the electronics of the public address systems, the application of cause and effect, to decipher the workings of prosperity gospel fuelled churches may also be unfruitful. The replication of neo-pentecostal practices , especially in worship, is, in our experience, progressing at an alarming rate into the synodical and historical churches. Could the absence of a rational understanding of the prosperity gospel phenomena be the reason for an ambivalent attitude of the church unity organisations ie Sierra Leone Christian Council and The Evangelical Fellowship of Sierra Leone, to comment on the effect these movements are having on their member churches? Or is their silence an endorsement of the influence of the phenomena on their member churches?

Pre Nuptials, Marriage and Procreation

We have been seeing far too much of the petrol pump of late, as we have gone a week without national electricity and needed to resort to frequent use of a small generator. Systems of public safety are not overly visible in Salone, so it was instructive to be told to wait a few minutes on the forecourt of the filling station, as a delivery of fuel was being taken from a tanker. One of the male attendants indicated to his female colleague that Peter was wearing a ring on the third finger of his left hand. This led to a discussion that began with the young woman insisting that a Salonean marriage only involved the exchange of cola nuts and not rings. This progressed as to why Peter’s wedding ring (like Janice’s) is silver and not gold. In the mid 1970s neither of us were keen to support South Africa’s Apartheid gold industry and opted for more ethically acceptable soft silver. The original designs were created using “silver” chewing gum paper and the actual rings were made by colleague friend at Middlesbrough College of Art.

That same day, we read an article in the British press indicating that the UK’s reputation as the divorce capital of Europe was under threat. This arose from the high court ruling on Katrin Radmacher and her French ex-husband, Nicolas Granatino, 38, a former investment banker, who had signed a prenuptial agreement before their wedding in London in 1998, in which it had been stipulated that neither party would benefit financially if the marriage ended. By a majority of eight to one, the supreme court justices dismissed Granatino's appeal, saying that after their ruling "it will be natural to infer that parties entering into agreements will intend that effect be given to them".

Marriage, and the ending of it contrasted with the invitation we were given to witness a Krio engagement ceremony the following Sunday evening in the home of one of our students, a short distance away, in Wilberforce village.

Our awareness of this rite of passage had begun in our Krio classes in the first half of this year and in addition to studying how the language operates, we were looking at some of the cultural and traditional practices of the Krios.

Sierra Leonean Krios are an ethnic group whose history dates back to the time of the trans Atlantic slavery. Their ancestors had been captured and shipped to the Americas or Europe as slaves, and following the abolition of the trans Atlantic slave trade in 1804, and a result of slaves having fought for America during its civil war, a number of them were granted their freedom, and to cut a long story short, with great difficulty returned to West Africa. The ancestors of the new arrivals could have come from any of dozens of West African countries where slaves had been taken from. Established as a colony to those given their freedom, Freetown and the Krio language, traditions and customs of those freed, developed and drew upon a variety of West African practices, particularly the Yoruba of Nigeria. Other influences include the practices, belief and rituals of Christianity that had been experienced and appropriated on the other side of the Atlantic.

One such custom that is still practised among Krios today is that of the announcement of an engagement prior to marriage, which takes place in the home of the bride to be. Our invitation to such an event came from Ronald, a student at College, as we were giving him a lift home one night. We eagerly accepted. Having heard the theory, in our Krio classes, now we could now see the experience the ritual.

The Dunbar family live in Wilberforce, a large, well established community, set up on high ground by wealthy Krios, and which features a recently installed statue of William Wilberforce. We arrived just before 7pm, and were introduced to Mr Conteh the spokesperson for the Dunbar family, who was sitting close to the door. A number of friends and relatives of the family were already seated in what is commonly referred to as the parlour.

Soon after 7pm there was a knock at the door. Mr Conteh responded, but did not open the door. A long conversation took place with those outside. Mr Conteh interrogated the people outside. “Why they had come, why and should they be allowed to come into the home?” Represented by an emissary, they had come to find a young woman who had been seen looking out from the veranda of the house, and they had a special message to give to her. Further questions were asked, through the door, about this event, and eventually the spokesperson felt sufficiently confident to let the people in.

There was a delegation of some 12 or more people, all with the intent of meeting the young woman, but only the emissary spoke. Dressed in an elaborate West African outfit, he traded dry, humorous exchanges as to whether there was such a young woman in the house, who had been spotted, as she looked out over the veranda. Eventually one woman was brought out from an adjoining room. No, she was certainly not the person who had been seen. After further questioning, a second young woman was presented. Aged about 2 years old, she was obviously far too young to have been looking over the veranda. Another attractive young woman came out, and much was made of her beauty, contours and breasts all of which invited admiration. The reply was polite and simple “all that all that glitters is not gold” as they were not identical to the shape of the woman seen on the veranda. Doubt was beginning to set in. Had the messenger made a mistake, was he at the right house? He was adamant. Surely there was another room that had women in it? The spokesman said that there was and he would go and make enquiries. After a while he came back, with a young woman who had looked out of one of the windows of the house. She was greeted with eagerness and respect, and yes, she did have lovely curves and beautiful facial features, but she had been looking out of the window and not over the veranda. So back she went.

While all this was going on, a sudden storm of wind and rain had got up, which caused a power cut. The family had a generator, which was started up on numerous occasions, but was not able to keep going. So it was necessary to resort to candles. To assist the inspection of the young women, torches on mobile phones came into play, to make sure that the right person was found.

After further wait, another young woman was brought out and presented. Immediately there was recognition, that she had been the one looking over the veranda. Then the discussion started as to why the messenger was so eager to find this woman. He had come to request her hand in marriage for a family member, and as a sign of the intention, had brought gifts for the family.

A calabash covered in a white cloth, was presented to the bride, which had kola nuts, (to cement the friendship, solidarity and generosity between the two families), needle and thread, (encouragement for the bride to be a good seamstress), bible, (for faith, prayer and Christianity), and a ring (symbol of the betrothal). Also in the calabash were envelopes with money inside, which were given to the bride’s parents, family members, and important supporters such as the local minister or pastor.

Then the messenger indicated that he had other more valuable gifts, non alcoholic whisky – With Honour I Seek to Kiss you/ Watch How I Sincerely Kiss You; that there would be a trip to Italy – I Truly Adore and Love You, and Holland was to be another destination– Hope Our Love Lasts And Never Dies.

The bride-to-be was called Ronty , from the names of her parents, Ronald and Betty. After the ring was placed on her finger, she proudly went round the room, to show her ring to everyone who eagerly waited to see it.

Up until this point in the proceedings the groom had not appeared, and wouldn’t for quite some time. His father, Mr Roby spoke of how Ronty would be welcomed into their family, and acknowledged the importance of both families being followers of Christian beliefs and practices. He then expressed his joy by breaking out into a chorus, which was received with much appreciation.

The time had come for light refreshments, which initially were pieces of cake and locally brewed ginger beer, but this was quickly followed with plates of bulgar wheat, kebabs, fish balls, and bread and butter, with a choice of “colas” or beers.

We chatted to the young man sitting to the right of Janice, to discover that he was a friend of the groom, William Charles and that through text messages he was keeping him informed of what was happening, but Ronty said that it was too early for him to come in. We discussed whether a similar tradition was kept by other ethnic groups such as the Mendes or Tembes, and were told that their practices and rituals differed, but for both groups, one essential requirement was as to whether the potential bride could satisfy the man’s sexual needs. We tried to ascertain whether proof of fertility would be necessary before marriage, and this could be so. The young man was called away by William but each time he returned kept us up to date as to what was happening.

Once people had eaten, they started to depart and eventually William appeared. Ronald introduced us to him, and for us it was then time to withdraw. The account that our Krio teacher had given had been replicated, and we felt honoured to have been witnesses to the drama. Unfortunately we will not be in Freetown on the day of the wedding. What a pity!

(Names have been altered and the "happy couple" have requested that their photos are not included.)

Matters of Life and Death: A Reflection on Health Care in Segbwema, Kenema District, Sierra Leone

Since my first extended stay in Southern Africa for a year before starting university, there have been several return trips to the West of the continent, both to gain experience with charitable organisations and for holidays. Whether fascination, curiosity or the refreshing change that comes with being in an environment that hustles and bustles to meet the necessities of daily life, there must be something which draws me to the continent. Five years through a medical degree, I have just returned from spending two months at Nixon Memorial Hospital, in Segbwema, a small town in the Eastern Province of Sierra Leone. At the end of my stay, I joined what appears to be an ever growing list of fortunate people, who have experienced Peter and Janice’s hospitality in Freetown. I hope I can add some reflections and comparisons of health in a very rural region of the country to their blog.

There is a place about a mile outside Segbwema simply referred to as ‘the rock’, where I would sometimes walk to on a Sunday afternoon. A scramble up a weathered track, past the derelict remains of houses that used to accommodate visiting doctors, rewards you with fantastic views across the tropical greenness that surrounds the village, with single storey dwellings and the new school scattered on the land in front of you. From the top of the rock, Segbwema is beautiful, serene and uncomplicated. This impression would be in stark contrast to how you felt on a Monday evening after a long day of clinics and ward rounds, where the complexity of the place revealed itself, both in the detail of malnourished children and women who suffered unnecessarily with complications associated with child birth, but also in glimpses of the compassion and often unanticipated humour that compose human nature.

Anyone who enters a role in the healthcare profession does so with the knowledge that, although many of the patients who they treat and care for will recover, there are some who will unfortunately not. The principle is consistent whether in Segbwema or London; what changes is the proportion of patients who recover or die and the frequency at which this occurs. The child mortality rate in Sierra Leone is among the worst in the world, with approximately one child in every five dying before their fifth birthday. During an earlier 5 week paediatric placement in west Wales, thankfully for the parents and children who visited the hospital, I had no exposure to children dying. On the third day of being in Segbwema, I was asked to confirm the death of a toddler. I had seen the child with the doctor thirty minutes earlier. She was malnourished with sparse, brittle hair and had a severe pneumonia. Antibiotics had been started, although there had not been sufficient time for them to have an effect. Walking across the busy ward to the child, I was facing both an emotional challenge and a practical task I had not had to confront before. I placed my stethoscope on her chest and heard nothing. No heart beating, no breath sounds. No reflexes or response to stimulation. Student nurses quickly wrapped the body. The mother came, stood by the child, sighed, and walked away. Then life continued in exactly the same manner as it had the thirty seconds previously. The routine, normality and acceptance of the situation was perhaps the most upsetting aspect. Child and neonatal death is, unfortunately, entrenched and ingrained within daily life in Sierra Leone. Whilst assisting at the antenatal clinic and recording the number and outcomes of a patient’s previous pregnancies, it was not an uncommon situation for the woman in front of me to be pregnant for the fifth or sixth time, with four or five live births and only one or two children alive. Inspired by my short placements on the labour ward and birthing units in the UK, I was keen to increase my experience of obstetric care. Unfortunately, I only observed two births, both of which were still births, one a normal delivery, the other at caesarean. However, another student who was also at the hospital was involved in births where there was a very positive outcome for both mother and child.

I fear that I am presenting too gloomy a picture of hospital life. It is often difficult to know what to express when trying to give an account of your experiences; attempting to get the balance right between describing the realities of the situation without giving the impression of hopelessness would not be true. There were moments of happiness too, both in hospital and village life. One young boy was admitted with a muddled and incomplete story about falling from a tree. He had significant abdominal pain and initially it was suspected he may have ruptured his liver or spleen, associated with a very questionable prognosis. However, a conservative approach was taken and in addition to other medication, he was given a trial of treatment for typhoid fever, which can also present with abdominal pain. There was considerable collective relief when on the fifth day he had recovered and was standing smiling next to his bed. Hope and happiness also came in the form of discharging children from hospital and seeing how malaria treatment and blood transfusion could transform pale, listless, almost lifeless small bodies into active healthy beings ready to continue being children.

The approach to medical diagnosis in the UK can often focus on the minute detail; a raised marker on a blood test or even down to the smallest genetic mistake in human DNA. In Segbwema, without X-rays, blood tests other than a malaria parasite check, running water or electricity for the majority of the time, medicine is practiced with the broadest of brush strokes. Fever is treated as malaria, diarrhoea often as a worm infestation and a cough as a pneumonia or tuberculosis. Temperature is assessed with the palm of a hand on the patient’s forehead and anaemia is checked for solely by looking at the colour of the patient’s hands or conjunctiva of the eyes.

Concerning treatment, the British National Formulary, the book of all licensed medicines in the UK, contains over 700 pages of small typed print of medications, the majority of which a hospital doctor in the UK can prescribe free of charge with little consideration of availability. In Segbwema there was a price list of drugs covering two sides of A4 to select from, often far less depending on what was currently in stock in the hospital pharmacy and the amount of money which the patient had brought with them. The interface between money and health is something which often does not sit comfortably with those in the medical profession. The questions of who, when, and how health infrastructure and treatment is paid for, dominates health systems all over the world. Limitations of funding occur in every health system, including the National Health Service in the UK, where headlines complaining at the lack of availability of the latest cancer treatments are common place. However, in Segbwema the relationship between money and health is crude and far more apparent at the bedside, with money often changing hands as the patient was wheeled into theatre for an operation.

In addition to spending time at a Nixon Hospital, I was fortunate enough to visit both a government run hospital in Kenema, a town west of Segbwema and a Fistula Hospital in Freetown run by the charitable organisation Mercy Ships. The differences in the standard of care and facilities available in these institutions, compared to Segbwema ,was substantial. The quality of clinical care delivered at the Aberdeen Fistula centre is not far from being comparable to a first class hospital in Europe, with well equipped operating theatres, a pharmacy and laboratory on site. Awareness of the significant differences in healthcare provision in different geographical locations and by different agencies is important for two purposes. Firstly it illustrates how a snapshot of experience gained in one small hospital in one location does no more offer a representative picture of the whole country, than the attributes of a single person could be used to describe the whole population. It also demonstrates the extent of the inequalities that exist within the same country, irrespective of the massive inequalities that exist between countries and continents. As health systems are developed, it could be argued that the distributive justice and fairness of the system is equally as important as the service the health system delivers.

Unexpected meetings and interactions were one of the most enjoyable aspects of my stay in Sierra Leone. One evening, we had a knock at the door of our house in the hospital compound and were surprised to be greeted by a very well dressed man who we gradually discovered had been studying for his PhD in Lampeter in Wales and was now running a campaign to be a candidate for the next president of Sierra Leone. One of the themes of his PhD concerning peace in Sierra Leone was that peace is more than the absence of war. In other words it takes a stable economy, social mobility, employment opportunities and social cohesion for a country to be truly peaceful. The parallels to health are evident. The World Health Organisation definition of health includes that it is ‘not merely the absence of disease’. Hospital life often sees the acute tip of the pyramid in the illness and suffering that walks or is carried through its doors, but medicine and healthcare provision cannot be seen in isolation from the wider context of housing, nutrition, education and employment. The integration of the multiple components that shape human life is needed to truly improve health. Although whilst I am writing this, I am putting off the job applications that need to be done for hopefully my first posts as a junior doctor next year, I look forward to being part of a profession that aims to contribute in a small way to enabling health and a profession that will hopefully enable me to return to Sierra Leone.

Robert Burnie, Cardiff, Oct 2010

Flagging It Up!

In pre independent Papua New Guinea in the early 1970’s, we witnessed the introduction of a competition to establish the country’s first national flag. Peter was working in a remote area of West New Britain, where a British volunteer was teaching, and so he was invited to take a break from building the new classroom, to take an art and craft lesson instead. Topically, Peter chose the designing of the national flag as his theme. Few of the children had ever ventured more than few miles from their rainforest homes, so the geographical appreciation of something as big as even a province, let alone a nation covering a large land mass , multiple islands and over 800 tribes, was an impossible task. Five years later we experienced the lowering of the Australia’s colours and the hoisting up of PNG’s first national flag, in black, red, yellow and resplendent with a bird of paradise, the country’s unique symbol.

On assuming power in Mozambique, following the long civil war, the victorious Frelimo liberation movement simply established their flag as the nation’s own. That it displays an AK47, the weapon of choice for freedom fighters, has not been sufficient to prompt a revision to be made to the nation’s flag during the last 20 years of the country’s peace. Whilst, this year, neighbouring Malawi, decided that after opting to display a rising sun on its flag in 1964, it was time to make the change to a fully risen sun.

In this year alone, 22 African nations will celebrate 50 years of independence. Last week, the continent’s most populace country Nigeria, which has one of the continent’s most un-distinctive flags, was acknowledging it’s freedom from colonialism amidst serious questions as to whether there was more to be reflected upon than celebrated.

As Sierra Leone begins to contemplate its own jubilee celebrations next April, a group of staff at the theological college are working on a project to combine both the nation’s milestone and the 35 years since the college’s inauguration. There is much to be considered, including how to remember the many people from a variety of nations who have contributed to theological education and nation building during that time. Meanwhile the green, white and blue of the Sierra Leonean flag invites a deep reflection on how it has been utilised, functioned and interpreted, at different stages, during the country’s fragile, democratic growth and for too long, a costly civil war.

The green band, at the top, stands for the nation’s agriculture, mountains and natural resources. As we are coming to the end of the rainy season it is indeed a verdant landscape that we witness across the nation. Agricultural produce is far less than it ought to be but a recent story from the Kenema District is more than worthy of flagging up and not just for lovers of chocolate.

When the war ended, a cocoa group called “Kpeya” which means "give way" in Mende, made a useful alliance with Africa's most successful cocoa cooperative, Kuapa Kokoo (Good Cocoa Farmers' Company) in Ghana. The company is the main source of fair-trade cocoa, in the UK and owns nearly half of Britain's Divine chocolate company, which had a £12.5m turnover last year – a share of which goes straight back to the farmers, including those in Kenema.

The white band at the centre of the flag represents unity and justice. The trial of the former Fisheries Minister concluded this week, with a guilty verdict being handed to Haja Afsatu Kabba, for misappropriating and misusing public funds. She now faces more than US$100,000 in fines or 15 years in prison. The verdict, which many had thought unlikely, given her prominent position among the nation’s political elite, was rightly applauded, as being a positive demonstration of the government’s attempt to eliminate wide-spread corruption wherever it is found.

The blue band, at the bottom, stands for the hope, that Freetown’s natural harbour , the deepest protected port on the whole of the west of Africa, will make a contribution to peace in the world, in the same way that the harbour offered freedom to the tens of thousands people who arrived into it, as a result of the ending of trans Atlantic slavery. Today, as a busy trading port the harbour also features in the needs of vulnerable new mothers and their babies too, as is evident in the story of Agnes and her new born baby girl Sia.

Agnes arrived at the last monthly gathering of the HIV positive group in Wellington, proudly displaying her 4 day old daughter. Both were warmly greeted, as Agnes told the story of how she had already visited The Mercy Ships land based hospital because of Sia’s hair lip. Because of Sia’s inability to suck, Agnes needs to express her breast milk, making feeding a precarious process. Resorting to formula milk alternatives only increases the possibility of life-threatening water born infections. Agnes had been told that an operation was not available at present, but would be so in four months time, when the Mercy Ship vessel will dock in port and begin its 10 months stay, with six surgical theatres on board, to address a whole variety of medical needs.

No doubt there are many more green, white and blue tinged stories in Salone but hopefully this biographical snapshot of the 50 year old flag will add colour to the viewing of your own much older national flag and perhaps the one of the country in which you read this too.