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.

Past and Present in Mission Partnership

Partnership in mission is the principle reason for our being in Salone, working with the Methodist Church and serving, in particular, in theological education.

Current discussions on the name of the college where we work, the Sierra Leone Theological College and Church Training Centre (SLTC &CTC), have involved the Minister of State for Education, as one of the questions has been of its appropriateness and accuracy – is it the only Theological College in Sierra Leone? If not, then what right has it to use the name Sierra Leone? In answer to the first question there are a number of other theological colleges in the country, representing various positions on the theological spectrum. But in her short speech at the opening service of the first semester of this academic year, Rev Dr Olivia A Wesley pointed out that SLTC is now working in Bo, Moyamba, Kono and Makeni, through its distance learning programme and so it has students throughout the country and therefore can justifiably lay claim to its name.

SLTC & CTC is an ecumenical college, having been established by three historical denominations for the training of their ministers – namely United Methodists, Methodists, and Anglican churches. Since its foundation in 1985, the curriculum offered, and the scholarship achieved, has grown significantly. In addition to degree courses in theology, and Christian education, accreditation has just been received from the University of Sierra Leone for the course in community development. 35 years ago it would have been hard to imagine that students’ numbers would exceed 350 , and that the majority of them would be pursuing studies in administration, information technology, finance and peace studies at certificate and diploma levels.

In 1985 all the students were from the three founding churches and situated in Freetown. Today the majority of the students come from independent African Initiated Churches, Pentecostal Churches and the Roman Catholic Church and some, are Muslims. This is also true of many of the teaching staff on the development, finance, and administration courses. This produces a diverse educational institution, where some courses are taught in a morning programme, but the major attendance is at evening classes, with community worship being an essential part of both programmes.

We are now into the first semester of the new academic year, and like all education institutions the college has experienced the inevitable timetable clashes, confusion of people moving from one course to another, and the uncertainty as to who is to pay the students’ fees. Whilst support is expected from the founding churches, the college relies principally on students’ fees, with additional revenue being derived from late assignments, exam fees, repeat examination fees, graduation fees, library fees etc. The list seems endless.

We are involved in both the morning and evening classes. Peter’s subjects for this semester range from The Gospels, to Christian Leadership and Church Administration, and Applied Theology, whereas Janice has English for Theology, Principles of Teaching, and Pastoral Action on HIV/AIDS. All of these subjects present challenges which need to be researched, as well ensuring that the methods used in the classroom do not conform to “I speak, you listen!!” In addition there are B.Th. dissertations and long essays to be supervised, as well as marking of these and other assignments. However, staff meetings are a rarity and almost all key decisions on functional matters (policy is controlled by the college’s board) are taken by a few key people and leaked rather than communicated.

Last semester we were involved in the preparation of materials for Distance Learning, which pursues the principals of education by extension, for the benefit of those living in isolated urban and rural communities. It is both an important aspect of what the college is able to offer as well as a response to the growing number of students seeking to pursue study, whilst also having the security of work in aspects of nation building, at a distance from major urban conurbations.

Within the student population based Freetown there is a reasonable balance of males and females, who vary in age but have in common a keen sense of wanting to learn, understand, assimilate and apply what they are presented with. Their academic backgrounds vary, some with the equivalent of a West African A levels, whereas others already have a degree in another discipline. Very few are full time students, in that they are not in employment, whereas many more are already involved in full time ministry or others working in a variety of occupations. Our academic colleagues are all Saloneans, but there are only two women academic staff members, in addition to the principal. A team of administrative staff and another, offering logistical services (including carrying water up three flights of stairs), provide invaluable support to the various strands of college life. Whilst English is the ‘medium of instruction’, Krio is the lingua franca, for all sectors of the community. For both staff and students football is the common topic of exchange, regardless of the day of the week, with much more being known about the English Premier League than local football.

The college library has a collection of 30,000 books but as yet is lacking a computerised classification system. Reading is a habit that needs much encouragement, and acknowledgement has to be given to the fact that many of the students may not have electricity in their homes, that they have very limited space to work in, and that with the close proximity of housing, finding peace and quiet to study is not easy, where the expectation is that people will socialise in preference to reading a book alone.

Early on in each semester a staff gathering is held which all staff full and part-time are expected to attend, although all are present, the content focuses more on the academic aspect of what is often referred to as the college family. The meeting this semester was a refresher course on learner centred teaching and classroom management, unfortunately with little demonstration of the former from two well respected women in the Ministry of Education.

The college celebrates various events during the year including graduation, which takes place in an open space at the front of the college. Students have a uniform to wear for such events, and if graduating, western style academic gowns. A sports day, and football competition are ‘compulsory’ for all and excitement builds up around these events.

The longer we are here, the more we find out about former staff members. On searching the bookshelves in the library, we came across a book by Margaret Baxter, a lecturer here in the 1980s. Thinking that we might find out more about her on the internet we discovered she had been awarded an OBE for her service to the community, in the New Year’s honours list, this year. The college hopes to produce a small publication to celebrate its 35th anniversary. One of the previous lecturers contacted is F Stuart Clark, and he too, we found, has a book in library.
Given the diversity of the courses on offer, the possible impact that those who pass through the college may have on society, is great. With its motto “The light of the world”, it is hoped that through the graduates’ lives transformation of Salonean society will take place by the imparting of peace building knowledge, Christian ministry and social action.