Out and about...

Another weekend in Freetown. I actually stayed close to home this weekend after plans to River 2 beach fell through. I still haven't been there since 2009! Friday afternoon I had dinner with some friends at Mamba Point and then went on to Roy's on Lumley Beach. I think Roy's has become my new hangout spot. There's an indoor restaurant and an outdoor raised platform with tables and chairs overlooking the beach. It has a nice atmosphere, great breeze and spectacular view. I actually ended up there Saturday evening again. Today I went up to church in Regent and was impressed that I managed to get a taxi from Regent back to Wilberforce for Le 1,000 (25 US cents) - I suppose it's the usual price for locals (that or Le 2,000) but as a white lady I am usually charged anywhere between Le 3,000 and 6,000. I won today. I'm now in Aberdeen using the internet at Mercy Ships (I must get my own at some point!) and going to walk on the beach for a bit later. It's been a quiet weekend.

I'm definitely out and about a lot more, having spent many evenings away from home, which has been a nice change. Of course, all of it is by public transport and so far that has gone smoothly. I do like being out amongst the Sierra Leoneans and attempting to do things their way. Last week, I did forego taking public transport when going from the hospital to home and decided to walk the entire way. In the end it took me an hour and a half. Which, considering it can take just as long by car in traffic, is not bad. It was quite hot though. I'm sure I'll do it again.

Someone asked me the other day if I have broken my rule and taken an okada (motorcycle taxi) yet... Nope, I haven't. And don't think I will. Even some Fullah men I was talking to at the roundabout this morning advised me not to. I'll take their advice. So for now, it's our own car with driver, taxis, poda podas or on foot.

The importance of prevention...

From: http://blogs.bmj.com/bmj/2010/10/26/sandra-lako-on-the-importance-of-prevention/

A few weeks ago a child came to the hospital with classic signs of tetanus: a locked jaw, rigidity of the muscles, and jerking of the body. The diagnosis was obvious. The doctors and nurses tried to cure the child, but in reality they had little to offer. The children’s hospital is not set up to manage these cases effectively. And so, a few days after admission, the child passed away and a preventable disease took the life of yet another child. Unfortunately the child was not immunised. This time it was tetanus next time it might be malaria.

Preventable diseases still make up a large portion of morbidity and mortality in Sierra Leone. Diseases like malaria, diarrheal disease, and malnutrition are rampant. Even tetanus is not uncommon. Although these diseases can be prevented, each one of them still takes an unnecessary toll on the children of Sierra Leone.

To win this battle a two-fold approach is needed. Curative services must be improved including adequate access to care, proper diagnosis, and appropriate treatment. Secondly, but arguably more importantly, preventive measures must be intensified.

Since the launch of Free Health Care in April, the number of patients seen at the hospital has increased. There are currently 8 medical officers and 2 house officers dealing with 1000 admissions a month plus outpatients. Add to this the inadequate diagnostic facilities, other staff constraints and a limited assortment of drugs and the challenge is obvious. Unfortunately cases that are easily treated in the developed world are difficult to deal with under such circumstances. However, progress is being made; a lab development project is underway, the radiology department is improving and there are significant steps being made in the area of staff training. All of these advances will aid in improving curative care. This is of course essential, since everyone wants sick children to be healthy again. However, although both approaches are crucial, prevention will have the greatest impact on lessening the burden of disease. Decreasing mortality is good, but reducing morbidity altogether is the key. Less illness means fewer hospital admissions, which in turn means that patients who are admitted can receive better care. And of course, less sick children should mean fewer children die. How can morbidity be reduced? The answer is clear: prevention.

Prevention is an integral part of public health in which health is seen as a basic right and should be maintained. Time and money spent keeping people healthy will have a huge impact on families, communities, and ultimately the country. The question is how to roll out prevention programs effectively in a developing country?

Examples of preventive measures include: hand washing, sleeping under mosquito nets, clean water for drinking, receiving immunisations, use of oral rehydration solution, use of latrines, ensuring good nutrition. It seems simple: make sure health messages reach the public and ensure that programs are delivered. However, implementation is where part of the problem lies. Simple measures can be difficult in a country like Sierra Leone where resources are limited. How does one promote hand washing, when water is not available? How can one expect a mother to walk for one hour to the nearest health post for immunisations when she has three other children to look after? These are the types of obstacles that stand in the way of effective programs. And, like anywhere else in the world, the biggest challenge is bringing about behavioral change. People need to be convinced that these measures will benefit them or they will not buy into them. In a society where traditional/religious beliefs are intertwined in daily life, behavioral change does not come quickly. This calls for perseverance from those delivering preventive programs.

Personally, I’m hoping that at the Ola During Children’s Hospital we will be able to focus more on prevention as well as continue to improve curative services. It would be great if the caretakers can be educated and in turn teach in their communities. One way in which this can be done is by showing health education videos in Krio as well as group sessions and one-on-one talks. Hopefully by taking the health messages onboard and implementing preventive measures in their homes, they will see that they can play a role in keeping their children healthy and happy. Hopefully an attempt will be made at all levels (ministry of health, hospitals, primary healthcare units, schools, religious places, etc.) to deliver high-quality, deliverable, and sustainable preventive programs. Sierra Leone, let’s make prevention a part of daily life.

Sandra Lako is a doctor from the Netherlands who previously spent four and a half years in Sierra Leone setting up and managing a pediatric outpatient clinic with an organisation called Mercy Ships. After a year at home, she returned to Sierra Leone to volunteer as medical coordinator with the Welbodi Partnership, a UK based charity supporting the only government-run children’s hospital in a country where 1 in 5 children do not reach the age of five.

Christmas Gift...

October 16, 2010.

It's 10 weeks until Christmas. For many people Christmas is a time to give. I know it's a little early, but this year, why not consider giving to the children of Sierra Leone - to those children who need your help to survive. Due to a shortage of oxygen concentrators in the Children's Hospital, children are having to share 5 liters of oxygen. Instead of 1 child receiving 5 Liters, it is split amongst 4 children. As you can see in the picture, the oxygen is split using tubing and connection pieces. Obviously this is not good enough and needs to change. I don't think parents in the 'west' would tolerate their child only receiving 1/4th of the oxygen needed to survive. Unfortunately the parents in Sierra Leone do not know any different. And the hospital is not able to bring about change in this issue in the near future. But I think that WE can make a difference. My goal is to raise £1800 by Christmas in order to purchase and transport 2 concentrators to the hospital in Freetown. Your donations will go directly towards this purchase. Please consider helping with this cause so that children in Sierra Leone will receive the care they desperately need. If you are interested please click on myjustgivingpage.

Thank you on behalf of the staff and patients at Ola During Children's Hospital.

Holland and Salone...

As much as I love being in Sierra Leone, there are definitely perks to being back in Holland for a few weeks. I forget about some of the simple joys of home. And it's nice to be away from a few of the annoying things in Salone, although having said that I am very happy to be going back tomorrow. I suppose every place has it's ups and downs. Below are some of the differences I noted while in Holland:

• Being able to drink water from the tap (and not risk getting sick!)
• Walking to town on my own without getting hassled
• Not being asked “Will you be my friend?” by strangers
• Riding a bike to town
• Getting on a train to visit friends
• Absence of car horns honking in the streets at all times
• The quietness in the neighborhood
• Eating cheese and drinking milk
• Good water pressure in the shower
• Not being asked for my phone number by anyone
• No loud music during the night
• Grapes and Pears (of course I'm perfectly happy with pineapples and mangos)
• No malnourished children seen on a daily basis
• Not needing to plan when to charge my phone based on availability of electricity
• Lovely brown bread
• Fast internet
• No random phone calls waking me up at 2 am
• Washing my clothes in a machine (not looking forward to the handwashing!)
• Wearing winter clothes (I’m not a fan, can't wait to pull out the flip flops)
• Seeing family (love you guys!)
• No need to lie about my marital status to avoid marriage proposals
• Watching television (although I don’t miss it at all when gone)
• Getting my blood tested including iron, vitamin B12 and folic acid levels (wow!)
• Lots of green grass
• Feeding ducks and petting well-groomed dogs
• Countryside with cows, sheep and horses
• Daring to get in an elevator assuming it won’t get stuck due to a power cut
• Traffic lights that work
• Well-organized public transport (although not nearly as adventurous)
• Not being confronted with children dying every day and the sound of mothers wailing
• Enjoying the outdoors

Ah. So many wonderful things. I've left it all behind now as I am in transit to Freetown. I am ready for all that awaits me there and eager to get back to work at the hospital. There are so many great things about Sierra Leone - just to mention a few off the top of my head - sun, beaches, friends, great colleagues, purpose in my work, adventures - lots of good and challenging times ahead. Salone, here I come...

Tribute to Opa...

My opa (grandpa) was a great man and I want to acknowledge that today. He was bright and influential. Not only was he a teacher but he was also actively involved in society as a musician and a politician. And at his funeral all of these aspects were brought to light. Opa had a positive influence on many lives. He will be missed.

Seeing as us kids grew up abroad we actually did not spend loads of time with opa as children. However, the times we did spend with him were special. I remember sleepovers at their house when we were on furlough - playing in the attic with all of our toys, riding opa's stationary bike in his study, eating french fries and applesauce, going to pick berries, rides on the sled, going to the petting zoo, story time. Opa and Oma did fun things with us kids when they got the chance. As an adult I tried to visit opa and oma when I could. But over the years, opa's health deteriorated yet he remained a caring and friendly opa.

Just before leaving Sierra Leone to come for my holiday I heard that opa had turned for the worse. I knew that this would likely be the last time I would see him. Shortly after arriving in Holland I went to see my opa, who had moved into a nursing home in the last 2 months. I spent 5 hours with him and my oma but for the most part opa was asleep. On Wednesday I returned for my final goodbye before going to a wedding in England. (The wedding was the whole reason for me making this trip) I was very fortunate (blessed) that opa was awake. I sat by his bed and talked with him and read Psalm 23 to him. As the minutes went by, my visit was drawing to an end. It was time to say goodbye. And this time, I knew it was the final goodbye. I am not sure if opa knew it as well, I suspect he did. With tears in my eyes I told him goodbye and said "I love you" and to my surprise (since he had hardly spoken prior to this) he responded saying "I love you too". These were our final words and this is also one of the last times my opa spoke. The next day he was unconscious and the following day he passed away. I was so thankful for my special farewell. I wouldn't have changed it for the world. The funeral service was a lovely reminder of who opa was and although difficult a good time of closure. I will miss my opa but I know he is now in a better place. Dag lieve opa...

Vacation...

20 days, 8 different beds, 1 wedding, 1 funeral, 2 birthdays and family time.

That pretty much sums up my vacation. The holiday was different than expected, mostly due to the death of my grandpa and the emotions that came with that and the time that took away from our immediate family but overall it was still a good time away. It was quite hectic though, moving around a lot, trying to plan around kids’ schedules, jet lags, trip to London etc. My time in the UK was great and Vez & Rob's wedding was fantastic. And as a family we did manage to go to the beach for a walk, eat at a Dutch pancake house, go to a family reunion (mom’s side), go for bike rides, etc. There was also some work to be done since I left Freetown in a busy period and some stuff just needed some attention. I didn’t mind though and am looking forward to being back. Despite the craziness and not having time to travel around and see friends I did enjoy spending time with my family especially since this was the first time we were all together since my brother’s wedding in 2007. I loved watching my nephew and nieces play together and seeing my parents with all of their grandchildren. Many firsts. We had some good times and fun photos to show for it. Hopefully it won’t be another 3 years before my family meets up again…it’s just difficult to plan when it involves families (small children and school-going children) and with us living in 4 different countries. We’ll make it happen though…

Night check at the hospital...

24 September 2010 - It’s 1:00 am. My colleague and I just returned from a surprise visit to the hospital. Three times a month we do spot checks on the wards; periodically we check during the early or late shifts and occasionally during the night and weekend shifts. The reason for these checks is that the Welbodi Partnership set up a performance-based incentive scheme a couple of months ago to monitor nursing care at the hospital with the aim of improving staff performance and ultimately reducing child mortality.

Unfortunately nursing care at Ola During Children’s Hospital has been suboptimal for a few years. This has various reasons, one of which is that for years salaries were low and nurses were forced to engage in work elsewhere, abandoning their posts at the Children’s Hospital. This caused a dramatic fall in nursing standards. Also, high consultation/medication fees meant that patient wards were half-full and patients often could not afford proper treatment and mortality rates were high. This was demoralizing and led to even more nurses not showing up to work. Lack of equipment and supplies worsened the matter.

Thankfully, a few months ago the government increased the salaries substantially, which led to an influx of nursing staff. For some nurses that was enough of a motivator to come to work when scheduled and perform well. Sadly for others, this was not enough of a motivation.

In April 2010 the Free Health Care initiative was launched for patients under-5 years. This led to more patient admissions and a heavier workload for the nurses. For some, this again made it difficult to stay motivated. Welbodi hopes that with the incentive scheme, nurses would be encouraged to provide better nursing care. For some nurses this works, for others, it doesn’t. There are many factors that contribute to this.

The set up of the scheme is to do spot checks using set criteria to monitor the level of care given. The criteria include checking if every bed has a mosquito net, if every patient has a sheet or ‘lappa’ to lie on, if soap and water are available, if all scheduled staff is present, if nurses are in uniform, if equipment is clean and well maintained, if sharps are disposed of properly, if patients vital signs have been checked, if medication has been given accurately, if the handover book is filled out, if the ward is clean and if the nurse’s station is tidy. The criteria are modified as time goes on and are often linked to what the nurses have been taught in a workshop.

Although the scheme sounds simple, it is actually quite complicated. The scheme looks at a ward’s performance, not an individual’s performance. So, if a colleague does not show up to work, the others on the ward are penalized. If a colleague has not documented medication properly, points are deducted for the ward and everyone is affected. It does not sound fair, but the idea behind it is that nursing care should be based on teamwork. When one person falls, everyone falls. Unfortunately we are not able to monitor each nurse’s individual performance because that would be a full time job. So, we look at the performance of the ward as a team. If one shift functions poorly, then the other two shifts will be affected.

Another matter is that the same scoring method is used on every ward, but every ward has a different workload. Obviously 3 nurses in the observation unit or measles ward will be able to handle their work load of 5 – 10 patients much better than 2 nurses in a general ward with 40 – 50 patients or 4 nurses in an ICU with 40 patients. Fortunately Welbodi encourages local ownership and makes sure to engage matron’s office in every check. This allows for Welbodi and matron’s office to discuss issues arising such as the number of nurses posted to each ward and so on. It also empowers matron’s office to enforce rules and the nurse’s code of conduct.

The actual checks are a bit of an adventure, especially the weekend or night checks. Sometimes it makes me a little nervous, not knowing what I will come across. Fortunately tonight was okay. Some things were not so good and definitely need to be improved/changed, but thankfully there were also areas that had improved. Most of the staff was present which was a welcome change from a few months ago. The main issue now is proper administration and documentation of medication but I am convinced that with more training, mentoring and feedback this too can improve. As I said before, it’s not simple. Constant monitoring and evaluation of the program is crucial to make sure the scheme still works towards improving nursing care. It needs to be a scheme that continues to encourage the nurses and not discourage them. Their job is not easy but it is so desperately needed and we need to help them find a way to regain a passion for what it is they do- helping the children in Sierra Leone.

The Clock Tower...

The Clock Tower from Sandra on Vimeo.

The clock tower, situated at Eastern Police in Freetown is a landmark for many. It is located at the intersection of some of the busiest streets in Freetown: Sani Abacha Street, Goderich Street, Kissy Road and Fourah Bay Road. Many people passing from the West or Center of Town will go by way of the Clock Tower when heading East. A whirlwind of activity surrounds the tower with street vendors trying to sell anything from umbrellas to pieces of hot dog to towels to fruit to sunglasses. Meanwhile pedestrians passing by are trying to stay clear of moving vehicles and weave their way through the street vendors. And the taxis, poda podas and okadas are honking their way through the city at a very slow speed often causing much of the congestion in town. It really is a busy place.

When the clock strikes 6 the most amazing thing happens. Besides the Westminster chimes, the clock actually has the National Anthem stored on a flash memory card so that when the clock chimed 6 times, Sierra Leone's National Anthem is played boldly from the tower. At this moment in time, everyone freezes. Vendors stop selling, pedestrians stop walking, market ladies stop their chatter, vehicles all come to a halt. Even the unknowing white person is called to a halt. The whole world seems to be at a stand still as the anthem plays. I love seeing it every time. It is like a scene from a movie. Lots of hustle and bustle and then all of a sudden, the world freezes as the anthem plays. And as soon as the anthem is finished, the whole world is on the move again. It's my Hollywood experience right in downtown Freetown.