The death of a child...

Last week there was an ultrasound workshop for the medical officers and I thought it would be interesting to join, so I did. The ultrasound room is adjacent to the emergency room so while we were waiting for everyone to arrive the internist and I were reviewing a few patients. There were many really sick children. One infant had been brought in due to rat bites, although I think the child must have been sick prior to the bites because the child was really unwell. Another child was very pale and in urgent need of blood. Another child had a very high fever and was convulsing. It was hectic.

After thirty minutes, the internist decided to begin the workshop, so off we went to talk about the ultrasound machine, the use of ultrasound as a diagnostic tool, etc. Meanwhile, the emergency department was bustling. After the workshop, we left the ultrasound room by way of the emergency room and I noticed two doctors resuscitating a child. However, minutes later they stopped, realizing it was ineffective. As I stood there and watched I could not help but realize that everyone else in the room carried on with whatever it was they were doing. The other caregivers were not paying much attention, nursing staff was preoccupied with other patients and even the child’s mother could not be found in the emergency room. In silence, the child passed.

After the doctors covered the child with a cloth, they slowly moved away, disheartened by what had just taken place. Meanwhile the now lifeless child remained on the bed and to her left and her right, two other children were struggling to stay alive.

Chills ran through my body as I realized again how much death, has become a part of daily life in Sierra Leone. The death of a child, that would bring masses of people to action in both the hospital setting and the home setting in the developed world, goes by almost unnoticed here. Why is that? It is because unfortunately 1 in 5 children do not reach the age of 5 years. It is not that the death of a child has no affect on people, but they react differently than someone from the West might expect. I’m starting to believe their response has to be different, or they will not cope.

The mothers wail to the point of throwing themselves to the ground in uncontrollable sobbing but seem to move on with life more quickly. They are told to “bear,” which means, “to put up with” or “endure.” They are told not to cry. To me this seems inhumane, but there must be reasons for this. Maybe it’s simply because a wailing mother will cause other caregivers to worry more about their own children. Or maybe it is easier for everyone else involved to cope better. Or maybe it is because in a place with so many child deaths, a mother somehow needs to accept that this time it was her child. I am sure that any time a child dies in the Emergency Room, the other mothers present are worried that their child might be next. What an unsettling thought that likely one or two more children will die in the emergency room today.

Of course the doctors and nurses are affected too, but rather than appearing shocked, they sometimes don’t seem phased by it. I am not saying this to be judgmental and obviously do not know what goes on in their minds but I have noticed how demoralizing child deaths are for the staff. Of course it hits them hard, but they tend not to show their emotions. They are frustrated with the lack of diagnostic facilities or treatment options to save a child’s life. They are irritated that caregivers tend to delay so much before bringing their child to the hospital. They are saddened that the health care situation is changing ever so slowly. When a child dies, the doctors and nurses tend to step back in silence. How long can they continue to give their all when the outcome does not seem to change?

Where the average doctors and nurses in the developed world rarely experience pediatric deaths, these doctors and nurses are faced with children dying every single day. How does one deal with children dying on a daily basis? I think that the only way one can continue to work under such circumstances is to distance oneself from the patients and guard one’s emotions. Clearly in a profession devoted to caring for people it is difficult to find a good balance between building a relationship with the patient and maybe even becoming attached to distancing oneself from a patient and becoming indifferent. When faced with death everyday one has to find ways to cope.

I do hope that the staff continues to cope with the dire situation and of course, hopefully one step at a time, the situation at Ola During Children’s Hospital will improve and child mortality will start to decrease. Maybe someday deaths will not be a part of daily life in Sierra Leone. One day. I just hope that until that day comes the doctors, nurses and other staff will continue to endure under such trying circumstances.

X-ray: coming soon...

The Ola During Children’s Hospital is very close to having the x-ray unit up and running. This is very exciting especially since it has been 6 years since the last x-ray was taken at Ola During. Can you imagine?

Currently children need to travel across town to Connaught Hospital for x-rays, which basically takes them half of the day to get it done and often they need to go back for the film and report the next day. It also means that children whose condition is unstable cannot have x-rays taken because there is no way to transport them safely, especially if they are in need of oxygen. There is no portable oxygen here. So, again, this is exciting.

The x-ray unit will complement the ultrasound machine in forming the radiology department, which is shared between Ola During Children’s Hospital and Princess Christian Maternity Center. In the end of June I was told that the Ministry of Health and Sanitation promised to deliver an x-ray unit to the Children’s/Maternity Hospital Compound. Honestly, I was a bit skeptical. However, they kept their word and mid-July an x-ray machine was delivered to the radiology department. Step one was complete, now onto the next step: assembling/installing the unit. This of course brought to light various hurdles but the doctor in the radiology department overcame them. The final step seems to be connecting the processor to the water system, although a temporary measure could be to use the old processor. It might sound easy to connect something to the water system, but believe me, the water system at the hospital is complicated and often very problematic, so this step to will take a little time. Soon though, the unit will be up and running. If the old processor is used, it could be as early as next week. I’ll be sad to not be here for that, but very happy to meet an x-ray unit up and running on my return.

Let’s hope that the x-ray department starts functioning soon. It will improve clinical care for the children and it will also bring the hospital one step closer to being accredited as a teaching hospital. Ola During is moving forward one step at a time...

Packing in a storm...

I was supposed to go out tonight, but there was a very heavy rainstorm; definitely what I would call a tropical rainstorm. The balcony doors were open, as were all of the windows in the flat, and within minutes I was dealing with a flooded living room. Ugh. I quickly went out onto the balcony to bring in the laundry and thought I was going to be thrown off of the balcony by the gusts of winds. I hope I rescued all of the laundry that was hanging up to dry! Four hours later and it is still raining.

So, although I bailed out on some friends, I am spending a rather enjoyable evening alone in the flat. Listening to music, washing my clothes, talking to my mom on the phone, writing blog posts, cooking dinner and … packing. Yes, I am going on a holiday. Normally I would not go on a holiday so soon (3 months) after arriving, however, a very good friend is getting married and I am honored to be one of her bridesmaids. Reason enough to go. So, it’s a brief stop (36 hours) in Holland and then on to the UK for 4 days, then to Holland for 12 days after which I’ll return to the UK to fly back to Freetown. I am excited to see friends and thrilled to see my family again. My whole family will be together for the first time since July 2007, which will be very special. My nieces and nephew have never met, which will be fun and my nephew has never met his great grandparents. Plus I haven’t seen my nephew and sister-in-law since August 2009. I am sure there will be many fun and amazing moments. However, having said all that, I think I will miss Sierra Leone.

Is that crazy? Someone who has lived here for a year went home last week and wrote that she missed Sierra Leone. Some people here thought that was a bit insane. However, I can relate. I suppose that because I really feel this is where I should be right now, I don’t really feel the need to go. Granted there are times I wake up at night and wonder what I am doing here and why I would choose to leave friends and family and go a thousand miles away but for the most part I love it. I suppose having spent over 4 ½ years here makes a difference, plus the fact that I do not have a tangible home anywhere else makes it easier for this to feel like home. Anyway, I’ll make sure to enjoy my break and have loads of fun and come back refreshed and ready to dive right in again.

"White girl"...

It is true that people in Freetown are friendly and you can easily strike up a pleasant conversation with someone while walking along. It is also true that while walking along the streets you will get comments left and right. There is a lot of “Hello, how are you?” or “Good afternoon.” It’s all pleasantries and part of being social but there are also the more annoying comments, and the comments that just get a little old. “White girl.” “Hey you.” “White woman.” “Apotto”. “I want to be your friend.” “Can I have your number?” And then there’s the hissing, which fortunately happens less than the commenting. Honestly, when it’s the children commenting it’s rather cute, but with the grown men it is annoying and when a women says “white woman” it’s just a little awkward. Still, all in all, it’s fascinating to walk, especially down town, although I suppose most of the time I am too focused on where I am stepping and making sure I don’t get hit by a car!

Rarely I’ll get the odd/rude comment. On Friday I was in the car with our new driver and we were ushered down a very busy road by the police. A street that both the driver and I have labeled as the street we hate the most in Freetown. Yes, that would be Sani Abacha street. Again, it’s fascinating but it is also very busy, with heavy traffic and literally hundreds of people selling along the sides of the street leaving little space at all for cars to pass. If in a car I am almost certain we’ll either hit someone or drive over someone’s possessions and if I am walking I am certain a car will hit me. It’s really not a very pleasant street. Anyway, we were driving along and of course the driver was doing the best he could to avoid the sellers who were well onto the road and couldn’t help but get close to people with the car. A lady (also well onto the road) yells at us saying the driver is driving badly because there is a white woman in the car. That annoyed both the driver and myself. First of all, he was not driving badly. Secondly why would a driver drive worse because I am white? We just kept driving but both of us thought the comment was ridiculous. Basically some people think that drivers of expats drive however they want to because the white are superior etc. as if white people do not respect anyone else on the road. Anyway it led to an interesting discussion between my driver and I about how Sierra Leoneans view white people.

Something else, that is also somewhat funny but also a bit bizarre is the number of people that will pull up and ask if you need a lift. I suppose I can’t blame the taxi drivers, that’s what they do, it’s their business. I had to laugh this afternoon when a driver called out to me: “Can I help you? I have a very nice taxi.” I said no thanks and continued the fifteen-minute walk to the flat. What is weird is when the private vehicles offer lifts. It just seems random. Do they really expect me to get in a private vehicle with a stranger? Then there are the expat drivers that stop and offer lifts. I guess in some cases, I would get in, like if it is another NGO, or VSO or someone I know (obviously). But occasionally you’ll get a white guy in a private vehicle offering a lift and then when you refuse (because he’s a stranger!) he is offended. Just because I am white and he is white does not mean I should hop in the car. Anyway, it just goes to show that most expats do not spend a lot of time walking around and people generally think you wouldn’t want to be walking, so offer a lift. They’re probably just being kind but they tend to forget that in the West you don’t get into cars with strangers. I’ll walk thank you.

So, for the most part traveling around town by car or on foot is quite entertaining, although the comments do get a bit annoying after awhile. All in all though, Freetown is a pleasant enough city to be out and about.

Pre-departure craziness...

This week has been full of meetings. I think it’s the pre-departure craze. You probably know what it’s like, trying to catch up with people and round things off in the week before going on a holiday. That’s my week. It started with a SLICH (Sierra Leone Institute For Child Health) Board meeting on Saturday and feels like it has been continuing non-stop ever since. The meetings mixed in with trying to fix a broken car have kept me on my feet.

First there was a meeting with the Disciplinary Committee at the hospital discussing the launch of the Committee, then a meeting with the heads of department concerning the disciplinary procedure, a meeting with the specialist-in-charge concerning the approval of forms for the medical charts, an ultrasound workshop, a meeting with my boss, a meeting with the lab technicians concerning a trip to the UK for training, a meeting with the two doctors traveling to Nigeria for their Primary Exams, a meeting with the other NGO in the hospital. It has definitely been a productive week, but I am glad that the weeks are usually a bit less hectic.

The funniest about all of these meetings is the difference in ‘style’. Where one meeting started at 8 prompt, others started an hour late or were re-scheduled to a ‘more convenient’ time. Some meetings were quick and to the point while others seemed to drag on and on. In one meeting, that seemed to have about 5 different closing moments, I thought picking up my notepad and pushing my chair back would have the needed effect to signal that the meeting should really end. It didn’t. Finally after another ten minutes I was asked if I would like to close the meeting. Quickly I adjourned the meeting! The other interesting thing about most of the meetings here is that people will usually answer their cell phones when they ring. This often includes the person chairing the meeting, meaning that everyone listens in on the phone conversation while waiting for the meeting to continue. It’s all very interesting.

On top of all of the meetings I am also trying to get last minute things done, like get the car fixed, sort out the finances, write up minutes to meetings, get a container of lab supplies cleared at the port, etc. Like I said, it is busy. But it is good. It’s hard to think that three months ago when I sat on the same chair, at the same desk in the same office I was trying to figure out what I was going to do everyday and wondering if things would fall into place. Well, I think I’ve found my routine and I can definitely say there is always enough to do!

Okadas, Poda Podas and Taxis...

I have taken more public transport in the past three months than the entire four-and-a-half years I was in Freetown previously. All I can say is it is quite an experience. Initially I was wishing for the luxury of nice vehicles with friendly drivers I knew from the past. Over time I think I have developed a love-hate relationship ship with public transport. At times it seems very convenient and easy, at other times it feels like an endless struggle. To be honest, I don’t mind it so much during the day but at night, I try to play it safe and at least charter a taxi from a known driver. Let me give you a quick run down of the public transport options.

To this day I have not taken an okada. To me an okada is like throwing yourself to the lions. An okada is a motorcycle taxi that weaves in and out of traffic at high speed usually without the protection of a helmet. When I first came to Sierra Leone in 2005 there were hardly any motorcycle taxis in Freetown but upcountry in places like Makeni they were abundant. They have now made their way to Freetown but they have not become a part of my transportation options as of yet. In my opinion it is an accident waiting to happen. Yes, you can tell the driver to slow down, but seeing as there are many careless drivers on the street I would not take the risk.

What I do often take is a poda poda. Poda poda means “hither and thither”. A poda poda is a minibus covered with painted slogans that takes as many passengers as it possibly can from one destination to another. It follows fixed routes for a fixed price and so even for the “white man” they are easy to use and you’re less likely to be told to pay more. Okay, so they are cramped, hot and noisy but they are also quite entertaining. Like the time that it was so busy in town and so hard to get a poda poda that grown men were climbing in through the window to get a seat! Or the time when we couldn’t make it up a hill being so weighted down and half of the people wanted to get out and walk while the others wanted to remain in the vehicle. This caused a good discussion and in the end everyone did what they pleased. The downside of poda podas is that when traffic is heavy the drivers only like to go “halfway”. This is very inconvenient and means that hundreds of people are on the street trying to push their way into poda podas. Sometimes as a “white man” you get squashed like everyone else, other times someone is kind and ushers you in almost making you feel guilty. All in all they are quite fun and convenient. I’d say they are safer than an okada, but honestly, they probably wouldn’t meet any safety requirements in Europe.

The final option is a taxi. Taxi drivers can be more flexible with their routes although many do have set routes. The taxi routes are generally a shorter distance than a poda podas but at a same price, so making taxis more expensive. This of course is relative since the rate is 900 Leones per route, an equivalent of USD 0.21. I could take one poda poda from town to my neighborhood, whereas with a taxi it would likely be a 3-way journey. However, the taxis are less crowded, stop far less frequently and often you can just ask the driver to continue on for another leg of the journey. There are a couple of taxi drivers who are reliable and friendly and I can call at anytime to arrange for them to pick me up or drop me off somewhere. This is more expensive of course at a rate of Le 15,000 per hour, an equivalent of USD 3.60, but at night this is ideal. Instead of having to walk down a dark road or street with groups of men hanging out, the driver can drop me off at my gate. It’s convenient.

For going to and from work it is easier to take our car but we have had major problems this past month with a driver I had to fire and then a car that wasn’t working. Hopefully by Tuesday I’ll head to work in a fixed car with a new driver! Tomorrow, I’ll take a chartered taxi into work and at the end of the day I’ll walk for 25 minutes from the hospital to Regent Road to catch a poda poda home, which can take anywhere between 30-90 minutes depending on traffic! For now, I am off to find a taxi to take me to Aberdeen.

A world away...

John Obey is situated only 35 kilometers outside of Freetown yet it feels like a world away. What an amazing place.

Refreshing. Breathtaking. Untouched. Welcoming. Stunning. Delightful. Captivating.

I can see why Tribewanted chose John Obey for their next eco-resort!

One in the crowd...

It’s 4:30 pm. I paid another visit to ward 3. Unfortunately, for some bizarre reason, there is no one to do ward rounds. I tried to get someone to come up but everyone seems busy. It’s unfortunate for the 50+ patients. I can just imagine the uproar that would occur had these patients been on a ward in a hospital in my home country. Parents would have demanded for their children to be seen. But here, the parents seem to have no voice. It is so rare for a parent or caretaker to question the way things are done. Often I wish they would speak up just a little bit and maybe it would get staff moving more quickly. Mind you, with limited human resources (doctors and nurses) things are simply difficult.

Earlier in the afternoon when I was checking if rounds had been done, I recognized a mom and child from the outpatient clinic in Aberdeen. The little boy had been a patient of mine, so had his older brother. I remember them well. This little boy is now three years old and has been admitted for a few days. I am not sure why I hadn’t seen him at the hospital yet. I guess because I am not doing a whole lot of clinical work plus the hospital is packed with patients. Unfortunately he was quite pale and had already been transfused twice. I was worried about him and hoped he would be assessed soon.

By 4:30 pm the boy had not been seen. The only patients that had been seen were 6 children who were well enough to be discharged. I guess the nurses asked a doctor to see those patients to free up bed space for new patients. Worried that it was already 5:00 pm and the night shift had begun with only one doctor on call, I thought I better assess the patient with one of the nurses. By now he was worse. He was obviously unwell, being very pale, with cold extremities and some respiratory distress. Something needed to be done. Now.

Fortunately one of the more senior doctors happened to be the one starting night duty. I told her I wanted to transfer one of the patients down to the Emergency Room/ICU and she agreed. So down we went. Fortunately the ER was not too busy. The patient was seen quickly and blood was drawn. He had a hemoglobin of 4.5 g/dL. Unfortunately he had already been transfused twice since admission and so I knew it would be hard for the family to get yet another unit of blood from someone. The blood bank here is dependent on relatives donating a unit of blood for the patient. I decided I would take the forms to the blood bank myself and plead on the child’s behalf. Thankfully the child had a common blood group and there was a unit of blood in the fridge, ready to be given to a patient. Within about 20 minutes I returned to the Emergency Room with blood in hand.

When I left the Emergency Room at 6:00 pm the boy was receiving the blood. He had also been given a bolus of fluids and put on various medications. When I said bye to him he told me he wants to see his big brother. I sure hope he can see his big brother soon. I hope I see him again tomorrow, improving.

I don’t want to take credit, and I am very thankful to the doctors and nurses who helped with this patient, but I cannot help but think that he would have died tonight had I not picked this very sick boy out of the crowd and transferred down to the Emergency Room. I am sure that I would have gone to work in the morning and heard he had passed away in the night. And that would have been that. I certainly hope the outcome will be different. I hope this little boy really can see his big brother soon. I'm a little anxious about what news the morning will bring...

Note from Wednesday 4:00 pm: I found out today that this little boy passed away at midnight. I'm speechless.

Rainy view from the balcony...

August is said to be the month with the heaviest rainfall in Sierra Leone. Yes, it did rain, but honestly, it was not too bad. I am sure I have been through worse rainy seasons. Needless to say, we did get a fair share of rain and the fact that they broke up our road to construct proper drainage along both sides made it all the more muddy. The rains may be starting to lessen (I think) and the contractors are a week or so out from finishing the drainage system, just in time for next rainy season! No, likely we’ll still have a good bit of rain in September and then come the spectacular lightning and thunderstorms in October. I actually don’t mind it too much, except for the dampness in the house and the mold appearing on my shoes and clothes. I suppose I am looking forward to the sunny days…

Lifestyles in Freetown...

While enjoying a lovely meal with a group of expatriates in a restaurant in Freetown I could not help but think of the stark contrast of how various expatriates in Sierra Leone live. While some expatriates rarely venture beyond the expat social circle the other end of the spectrum consists those expats who live with nationals and hardly see other expatriates at all. Neither is right or wrong but I think I can say I prefer something in between the two.

Living with nationals would have many of its own challenges: limited to no water and electricity, different food, language and culture barriers, limited privacy etc. But on the other hand, it would be very enriching and a unique cultural experience. However, when dealing with so many issues all day long when working in Sierra Leone, I think it is nice to get a little break from some of the daily issues. I am impressed with expatriates that can pull this off, I am just not sure I could cope.

The other end of the spectrum is much less appealing to me and I am often shocked to hear that there are people who come to Sierra Leone and have very limited interaction with nationals whatsoever and end up living their Western lifestyle right here in Freetown. It is hard to imagine but I suppose it is possible. They spend their days at the office, their travel time in 4x4s and their free time with other expatriates dining out or enjoying the endless expat party scene. Food is purchased in restaurants or bought at the supermarket and prepared by a cook and life seems to be all about convenience and luxuries. They are here to get a job done. A different approach to life in a developing country, but for some people, this is what it’s about. I cannot say it is wrong, but it definitely would not be my choice of lifestyle.

I suppose my way of life is somewhere in between; living in a fairly spacious flat, socializing with my expatriate friends but also working with the nationals, meeting up with nationals and being part of a smaller national community in Regent. I have no access to cooks, cleaners, washing machines, and no means of transport at the moment so my way of life is a bit more basic in comparison, having to do my own shopping, cooking, cleaning, hand washing and taking public transport. I must say, from my previous time in Sierra Leone how nice it was to have these things and it’s been a bit of an adjustment to do without. However, in comparison to how the average family in Freetown lives, I still have it easy. It’s not a life of extravagance but I definitely cannot complain. I can enjoy the people, the language, the culture and still enjoy some of the simple luxuries such as decent electricity, water, chocolate and a meal out once or twice a week.

I guess the contrast is partially due to a difference in income levels, however, some of it has to do with attitude too; not only attitude but also motivation for being here and the degree to which one wants to take part in a new culture and people group.

Of course this stark contrast does not only exist among expatriates, but also among Sierra Leoneans. In 2005 I remember that Sierra Leone was ranked at the top for having the largest gap between the rich and the poor. Basically there are a lot of very poor people in Sierra Leone but also a lot of very rich people. Their ways of life are also very different to each other with some living in mansions with generators and running water to others living in small over-crowded shacks lit by kerosene lamps without a water source nearby.

I suppose in reality, these differences occur all over the world, whether in Sierra Leone, the USA, the UK or Holland. Everyone lives with different standards. Some people mingle in with their local communities and others do not. I suppose this is nothing new. It is just something that crossed my mind as I was sitting in a restaurant enjoying a meal with a very diverse group of people in the middle of Freetown.