Wake up world: stop tolerating harmful medical practice...

As you likely know, I am a qualified and registered medical doctor working alongside national staff in a facility that is run by a UK foundation and supported and registered by the Ministry of Health and Sanitation, providing outpatient medical care to sick children below 16 years of age. The severity of illness we deal with ranges from a child with a runny nose to a child who is unconscious due to severe malaria. Regardless of the situation, our team acts based on our training and experience. Yes, we are forever learning, but through years of training, we have been equipped to handle such situations. I cannot even begin to imagine managing critically ill children with no medical training.

I am shocked but not too surprised to read the story of Bach, who according to this article, went to Uganda as a 20 year old highschool graduate with no medical training, and ended up running a centre for children with severe acute malnutrition for five years, performing medical procedures herself. If these facts are true, this is wrong on so many levels. And sadly, stories like this are a reality in many developing countries. 

This would not be the first time a possibly well-meaning, but naïve or ignorant, individual sets out to help others but puts lives at more risk. Some might call it the White Saviour Complex. Whatever you call it, it is appalling and needs to stop. Whether it is foreigners coming in to “help” or nationals "helping" their own people, if they are working outside of their realm of expertise or doing more harm than good; STOP THEM. If the facts are accurate, it is also infuriating that Bach's friends, family and Board did not intervene but applauded from the side lines.

I don’t have more details than what is included in the article linked above, but I know this is a global issue and I believe we can and must do better. We owe it to ourselves and we owe it to those we care for. The world needs to wake up. So, here are some reminders...

Common sense: 

• Don’t do what you’re not qualified to do.
• Always make sure that what you are doing is legal.

Responsible humanitarian aid: 

• Don’t think YOU can save faulty systems or the world for that matter.  You may be able to help, but you are by no means THE solution. 
• Work alongside local authorities and nationals on a long-term sustainable and coordinated response. 
• Do not do your own thing.

Appropriate support and sponsoring:

• Know who and what you are supporting.
• Make sure the charities you support are law abiding.
• If you know that someone is working in a capacity overseas that would not be acceptable in your own country, strongly advise them to stop.
• Advise people you support overseas to work alongside nationals who know far more about their setting and context than a foreigner ever will.

Wake up call for local authorities in developing countries: 

• Supervise and monitor all of the so-called health facilities and professionals. Put clinical governance systems in place. I know that in Sierra Leone, there are “clinics”, pharmacies and healthcare workers working outside of their legal boundaries, providing potentially harmful care. Some do more harm than good and should be shut down. Why tolerate it at someone else's expense? 

Building a good health system does not only mean improving standards and ensuring high quality care but it also entails regulation, which means shutting down illegal and/or unsafe health facilities and revoking licenses of those who do more harm than good.

#wecandobetter #sierraleone #healthcare #clinicalgovernance #healthsystems #partnership #collaboration  #regulation #moreregulationneeded #ethics #healthramblings #commonsense #dogoodnotharm #supervisionandmonitoring

Another year...

Today marks the first day of another year at Aberdeen Women's Centre! Yesterday, I completed my first year working as a doctor in the outpatient paediatric clinic. There was a lot of transition at the start, including a move to a new home, resuming clinical work and starting my online Masters in Public Health and at times I wondered if I would make it to the end of the contract. Thankfully, I did and I’ve decided to stay put for another year.  

Although there are parts of my work that are frustrating and challenging, like any job I suppose, the work I do in Aberdeen is also very rewarding. I have the unique opportunity to help children get better and advise and encourage the caregivers to provide healthier environments for their children, whether it’s through nutritional advice, encouraging them to bring their children for immunisations or teaching them how to prevent illness. It’s a privilege to work alongside a Sierra Leonean team and provide healthcare that makes a difference in the lives of children and families in Freetown.

Now that the rains have started, the clinic is even busier than usual and in the past three days alone we’ve treated over 400 patients. We are seeing more diarrheal disease, respiratory disease, as well as cases of severe malaria, in children of all ages. At times it’s scary to see just how sick these children can get but on the flip side, it is amazing to see how so many of them recover. I’m hoping for ongoing wisdom and energy for our team as we strive to help as many children as we can despite the craziness and long days. Here’s to another year at AWC.  

Being the patient, what to do...

Even though I don't feel sick, I do have a medical problem which I have to see a GP & specialist for, so I guess in theory that makes me a patient. Thankfully, I am rarely 'the patient'. I have been very blessed to stay healthy over the past 7 years in Sierra Leone, with only 3 sick days in that entire period and a few minor illnesses here and there.

So, I guess the question is, as a doctor what do I do when I become the patient? Do I:

a) self diagnose and treat

b) ask a colleague friend for advice

c) ask your sister (a GP) for advice

d) go and see your GP

e) leave it and risk waiting too long?

I suppose for me it depends on what's wrong and where I am at the time. If in Holland, I think I would go to my GP fairly quickly. In Sierra Leone, I'm more inclined to sort it out myself. Especially if it's something minor, like a skin infection or eye infection: I self diagnose and treat. Pharmacies are scattered throughout Freetown and medication is easy to come by, which is convenient but not always so reliable. I generally stick to the one pharmacy that I believe has good quality drugs. Having said this, when I had an abscess just above my knee I self-treated and even ended up doing some very minor 'surgery' on my leg. At that point I got a bit worried, wondering if my leg would be okay. I had reached the point of considering checking with a colleague but fortunately after 48 hours of antibiotics (doubling the dose to the maximum!), my leg looked better and I could walk normally again and there was no need for a consultation.

Likewise, if I had a fever I would probably head down to one of the few laboratories I trust (because I know the technician) and get tested for malaria. If positive, I would self-treat with the same thing I prescribe for my patients, if negative I'd wait it out. And, after two days, if I was not better (or if I got worse in the meantime) I would go and see a GP in town, possibly after checking with my colleagues or sister.

I think asking for advice from colleagues or family can be quite helpful. However, I also realize it puts them in a difficult situation. I know this because I have been in that situation a number of times. It's hard to be objective when you're treating/advising someone you know well. So, for the most part, I would ask for their opinion but generally not have them treat me.

So, how do I decide what to do? I guess part of the decision making has to do with my own experience in treating patients - if it's a condition I'm familiar with, I would self-treat. However, if it's something bizarre, I'd be more inclined to get it checked out. The same goes for treating colleagues, friends, expat children - I am happy to help/advise, but if it's more complicated and they need to be seen properly, i.e. more tests, full physical, etc, then I would refer them to a GP in town. (Remember: I don't have a clinic of my own and am not doing full-time clinical work.)

Part of the decision-making also has to do with the quality of care available in Freetown, or lack thereof. Sometimes it might be better to try to sort it out yourself or go to a colleague you trust, rather than some random clinic. There are a lot of random clinics in Freetown! You need to know where to go. With my anemia for example, I was happy to check my Hemoglobin myself. I wasn't as convinced to go to local labs, because I wasn't sure if I would even trust the results. Plus, knowing I was going to Holland, I decided to wait and get it done properly. So, on arrival here (after consulting my GP sister, I have to admit), I went to my GP and he got the ball rolling. It did come to the point where I could choose to go back to Freetown and go to a local lab/GP once a month or stay here and get things sorted out first. For reasons mentioned above, it seemed wise to sort things out in Holland. So here I am, 3 1/2 weeks later...

Cholera situation reminds me to be thankful...

I’m currently staying in a house with friends in The Netherlands while waiting for my return to Sierra Leone. I have a roof over my head that does not leak, continuous access to clean drinking water and good sanitary facilities. Meanwhile, the Cholera epidemic continues to spread in West Africa.

As of September 3^rd, 15,834 cases, including 251 deaths, have been reported in Sierra Leone. All but one of the 13 districts nationwide are now affected. In Guinea, its neighboring country, 5,699 cases, including 109 deaths, have been confirmed. This is yet another example of people suffering and dying from a preventable disease. With rainy season continuing, chances are cases will continue to rise.

It is so easy to take things for granted. So often I worry about things that don’t seem to be going the way I think they should in life and I forget about the amazing blessings that God has given me. I forget how fortunate I am compared to those around me. Even in Sierra Leone, where I can’t drink water out of the tap, I can still afford to buy packets of clean drinking water from a shop nearby. At the same time, my neighbors stand in line to collect a bucket of unclean water from a standpipe, 10 minutes from my house.

According to Unicef, only 12.8% of Sierra Leone's 5.5 million people have access to proper sanitation, while 42.9% do not have access to clean drinking water; 28.9% defecate in the open. Who am I to complain?

Although I’m far away and can’t do anything about the cholera situation at the moment I can remember to be thankful. Today I am thankful for clean drinking water, a roof over my head and good plumbing (and good friends who have kindly let me stay with them for longer than expected!). Take a few minutes to name three things you are thankful for.

For more about the cholera situation, read: http://gu.com/p/3a6j8/tw

Second blood donation...

After a four-month wait, I was finally allowed to donate blood again at the Children's Hospital. I still think it's crazy that women have to wait 4 months, while men can donate after 3 months but rules are rules. Anyway, after lunch on Good Friday (great day to donate and reflect on the blood Jesus shed for us!), Shona and I headed to the blood bank to donate. Last time we enjoyed Christmas music, this time we enjoyed an Independence song serenade by yours truly: Omar.

I have to say, the whole process is quite amusing every time we donate. My Hb was 12.3 g/dl this time I believe, which is not bad considering I hardly eat meat these days. And I lost 3 kilograms since the last time I donated. I won’t complain about that either. So, Hemoglobin fine, weight fine, ready to donate. And that’s when my least favorite part comes in- the big big needle needs to be inserted into my arm. Ouch. And unfortunately this time, shortly after the needle was in place, the blood stopped flowing. After some slightly painful maneuvering, the blood still didn’t want to come out and so we decided to give it another go. This meant a second needle stick. Fortunately this time, the blood flowed quickly into the collection bag. And there was a fresh bag of blood, waiting to help one or more women or children.

I love the thought of helping others in such a tangible way. And what does it cost me? A little time and a little blood. Oh, and two needle sticks this time. I would again encourage everyone in Freetown to come and donate blood at the Children’s Hospital; every 3-4 months please. And really, if you come, I’ll buy you a coke!

Trip to Namina's village...

On Saturday the 5^th of March I woke up at 6 am. I had a big trip planned- a visit to Namina and her mom in their village. Farrah, a taxi driver friend of mine came to my house at half past 6 and after loading up a huge bag of rice and some other gifts for the family, we headed towards town. On the way we picked up one of my former colleagues, Ramatu, who used to work with me as a nurse in the Aberdeen outpatient clinic.

By 8 am we were on the ferry, heading towards Lungi. From Lungi we were told it would be a 15-minute drive to Bailor town, Namina’s village. Wrong. We picked up her older brother Saidu, to show us the way and after 25 minutes we found ourselves in a remote area, driving in and out of very small villages. Saidu kept saying we were almost there. We came to a bridge and wondered if we could cross it. Saidu said taxis do it all the time. So Farrah braved it. The crossing was very noisy as the loose planks were moving about under the tires of the car. I loved watching Farrah’s face as he was driving across the rickety bridge. He was happy to make it to the other side and already dreaded having to cross the bridge again on the way back!

After 75 minutes we reached Bailor town; a peaceful village on the beach surrounded by palm trees. The people were friendly and of course Namina and her family, including her granny, were thrilled to see us. Many children crowded around fairly quickly to get a glimpse of us. I was happy to see Namina and Wara again, and loved the fact that I was able to get a glimpse of their lives.

With all of the children in tow, we walked to the beach and enjoyed picture taking and refreshing sips of coconut water. There was laughter all around. It was great to see Namina in her own environment. We walked further down the beach and then turned back up to the village and back to Namina’s house.

A few hours later we were served food. Culturally, the guests are given food and everyone else waits to eat at a later time. So the three of us were served a wonderful meal while everyone else remained busy in the kitchen or in the house. I would have loved to sit down and eat with everyone, but I know this was a way for them to show their appreciation and respect. Their hospitality meant a lot.

When we realized we would miss the two pm ferry, we sat around and talked some more and then left in time for the 4 pm ferry. Of course, we had to cross the bridge again. And this time, we actually got into trouble- the tire slipped through the planks and was stuck in between the metal bars of the bridge. After trying various tactics, we managed to get the car tire out. We went on our way again, thinking we would miss the 4 pm ferry but in the end, there was no 4 pm ferry and had to wait for the 5:30 pm ferry. I think we were home by 7:30 pm.

The visit was eye opening and I will treasure the memories. I was happy to see where Namina and Wara live and grateful for their hospitality. I think what I was reminded of most from the trip is Wara’s commitment to her daughter. Wara’s husband died a few years ago and she is now the sole caretaker of 7 children (of which two are above age 16). I thought about our journey to Bailor town and back – the cost, the time, the distance, the effort, the challenges. And I thought of Wara making that same trip every single week to get Namina to the clinic in Aberdeen for her wound care. They would take the ferry on a Monday, stay with relatives in Freetown, come for Namina’s appointments and then head back to Bailor town on a Friday evening. And Wara did this for months on end and never complained. Wara was determined and dedicated and I can certainly learn from her. It is her perseverance that pulled Namina through. And after months of follow-up and more months of waiting for the ship, it was a delight to be able to take Wara and Namina to the ship for Namina’s admission. I feel privileged to have played a part in Namina’s story and am glad that I will continue to be involved in their lives.

World Malaria Day 2011...

Today is World Malaria Day and unfortunately, although a preventable disease, malaria still kills many people in the developing world. At the children's hospital I work at, we see malaria cases everyday. Some cases are very severe; the children are literally on death's doorstep and other cases are mild and improve with oral medication. As you can imagine, the disease has a major impact on child health in Sierra Leone.

In November of last year, we had 999 inpatients in the hospital and in that month (as often is the case) malaria was the most common reason for admission, followed by chest infections, diarrheal disease and anemia (unrelated to malaria). Sadly, children die at the hospital on a daily basis. In November, 54% of the hospital deaths were attributed to malaria. In November 67 children died at the Children’s Hospital as a result of complicated malaria. We obviously have our work cut out for us. Having said that, I do believe that the staff at Ola During is working hard to do their part in combating malaria. The staff, management and partners of ODCH and the Ministry of Health and Sanitation must be commended for their ongoing efforts to improve healthcare. The laboratory has definitely improved and more blood smears are being examined for malaria. Thanks to one of the partners in the hospital, malaria treatment is readily available. Improvements in the triage and emergency system mean that children receive their treatment more promptly. There is still a lot to be done, but progress is being made.

The theme for the fourth World Malaria Day is Achieving Progress and Impact. The theme recognizes the international community's renewed efforts to make progress towards near zero malaria deaths by 2015. We’re not there yet, but I like to believe that things are improving. Hopefully the country of Sierra Leone can tackle issues like: distribution and use of insecticide treated nets, prompt diagnosis, appropriate treatment, etc. Various barriers play a role, such as: cultural/traditional ideas impacting use of nets and quick presentation of child to a health facility, lack of experienced laboratory technicians, lack of rapid diagnostic tests, inconsistent supply of ACT medication or quinine, etc.

Hopefully, health education in the communities, training in health facilities (lab and medical staff), and improved supply chain will decrease the number of deaths related to malaria in Sierra Leone. The day that there are near-zero malaria deaths in the country will be a day to celebrate for sure. Count me in…

(see: http://www.worldmalariaday.org)

Screening: the highs and the lows...

On Monday I had an early start, reaching the national stadium at 6:45 am for the Africa Mercy Screening day. When I arrived, I could already see hundreds of people waiting outside and I could only see a portion of the crowd. I was excited to be a part of this day, a day of expectations, and a day that was sure to end with much rejoicing. At least, that is what I thought.

After the organizers cleared up a few small issues with ‘extra’ lines, the screening soon began. One by one people entered the stadium grounds; the first stop was the pre-screeners. The pre-screeners asked people their reason for coming and then proceeded to tell them whether or not they could see a doctor. Due to the specific nature of the conditions treated onboard, there are always people that show up at a screening that cannot be helped. The pre-screeners had a tough job, but it was definitely needed in order to effectively screen those patients who were suitable candidates for surgery. I was impressed to see the pre-screeners persevere, patient after patient.

For those with conditions that could most likely be dealt with, the process continued as they made their way past a few more stations to the specialist screening areas: orthopedics, maxillo-facial, plastics and general surgery. It is there that they find out if they will receive surgery. To me it seemed as though this was a critical moment for patients, since the news they were about to hear could change their lives drastically. And it was these moments that were the most meaningful to me.

I was at the maxillo-facial station with Dr Gary, primarily to learn from him. The station consisted of three tables, each with a dentist and a translator to start the screening process. Dr Gary, the maxillo-facial surgeon, rotated between the three, seeing each patient and making a (differential) diagnosis and plan. It was remarkable to work with Gary and discuss/see conditions such as thyroid glossal duct cysts, cleft lips, neurofibromatosis, fibrous dysplasia, lymphomas, TB adenitis, and encephaloceles. He not only has a wealth of knowledge and experience but also worked with such confidence, humility and care for the patients.

Besides the sheer excitement of being a part of such a big undertaking and knowing that many people would be scheduled for surgery, it was awesome to watch the faces of individual patients light up when they heard they would receive an operation. Imagine a dad and his boy smiling when they heard the boy would receive surgery for a growth he’s had since birth. A woman thrilled to hear she could be operated on. A young guy, happy by the mere fact that he was being assessed properly and scheduled for a CT scan for further investigation. A shy 13- year old girl, hearing she can receive cleft lip surgery. It is these moments I try to remember when thinking about the screening, because the joy was quickly overshadowed by the tragic event that took place.

As mid-morning approached, the crowd became impatient and people started pushing forward. Those in the small, gated entrance to the stadium grounds were trapped. To relieve the pressure, a small gate was opened and people ran out, forming a new line. The situation quickly escalated. The pushing and shoving worsened and within minutes a larger gate opened and those pressed up against the gate, flooded out of the small space, onto the pavement. A stampede followed and the consequences were grave.

Within minutes, casualties were brought to the pre-screening area and there was a rush to attend to the victims. Some were in a serious condition while others had fainted or were still in shock after having been confined in a small, overcrowded space. Despite good efforts, one man died that day and 13 more were injured. This was not how it was supposed to end. A day of anticipation, excitement and joy, ended in a tragedy. It was very difficult to carry on but it seemed wise to continue screening those in the stadium. After an hour however, the situation outside grew tense once again and the decision was made to stop screening and leave the premises.

With heavy hearts the 200 crewmembers that put a lot of effort into the day, returned to the ship. Meanwhile, I walked back to the hospital still in shock at what had happened. How did the situation get out of control? Is this the Sierra Leone I know? I was saddened that the screening had to end like this. Saddened for the crew, the family of the man who died that day and saddened for the people of Sierra Leone. I couldn’t help but think that somewhere in Freetown there might be a family waiting for their father to come home, but he won’t. I kept thinking about the patients needing surgery, still waiting outside of the stadium to be seen by a doctor. I think about those who were caught in the stampede and traumatized by what happened. I think of the crewmembers that have come to Africa for the first time and experienced such a tragic introduction to what is actually an amazing country.

Looking back, part of me wishes I did not go to the screening that Monday yet a bigger part of me would not have wanted to miss the priceless smiles of those who heard they would receive surgery. There were highs and there were lows that Monday. However, I know that this is just the beginning; the beginning of something good. Although it was a very unfortunate beginning to the outreach I am convinced that despite all that has happened the Africa Mercy is going to have a huge impact in Sierra Leone and many lives will be changed. I am sure that those in urgent need of surgery will be scheduled somehow, at some point. The ship’s visit has been anticipated for years and now the time has come. Great things are going to happen. For those of you who pray, do pray for the crew onboard the Africa Mercy. This is not an easy time. Pray also for wisdom for those in leadership who are planning the next screening.

Hello Sierra Leone...

In less than 12 hours I will be airborne (again) and on my way to Freetown, Sierra Leone via Malaga, Spain. And I can't wait. Well, I am not too excited about the actual trip, but I'll be glad to be back in Salone. Back in my own place and ready to get back to work. I'm going to count on one of my two trusted drivers to be able to pick me up and drive me home, that is, once I take the water taxi from Lungi to the other side.

Have I really only been gone for 12 days? It seems like weeks have gone by. It's been good to get a bit of distance but I really am ready to be home again. I'm looking forward to seeing friends again, going to the hospital, being at the women's group, enjoying the sun (although I might change my mind when I'm all sweaty), etc. I'm not looking as forward to the dust - and the forever dirty feet and the lack of a washing machine and internet. But for the most part, I'll be happy.

I guess my only concern is that I already know I am going to hit the ground running. There are meetings that need to take place with the Ministry and UNFPA, more oxygen concentrators arriving, work to be done on the lab project, medical records/database issues to sort out, liaising with other NGOs in the hospital, preparing for the next SLICH (Sierra Leone Institute of Child Health) Board meeting, and the list goes on. I told you I was concerned. Besides this, there's a big white ship arriving next weekend and along with that comes a list of people coming to Sierra Leone to connect with the ship that I would like to see while they're visiting. My social life is going to be a bit busy. But fun. Anyway, work wise my plan is to continue making 'to do' lists but to prioritize them properly. And focus first on those things that need to be done urgently and basically make sure those get done. If I can at least get the top 4 things crossed off of my list everyday I think I'll be okay. Maybe my goal should be to make sure I have one day (Sat or Sun) that I do absolutely no work, at all. Yeah, we'll see.

Alright, I am going to get some sleep before the day really begins. And, I hope you've enjoyed the regular blogging- I'm not sure if I can keep it up when in Freetown, unless I get internet at home sorted! I'll do my best...

"Oxygen for Christmas" = a success...

Over the Christmas holiday $11,760 was raised for oxygen concentrators for the Children’s Hospital in Sierra Leone. This is enough for at least 8 new concentrators! I was amazed to raise $5,000 last year for charity: water, this year I’m blown away! Friends, family, churches and strangers have all given generously to this cause. THANK YOU!

With only 6 oxygen concentrators at the Children’s Hospital, children had very limited access to oxygen. Often one machine was shared between 4 children! (see above picture) Obviously this is not sufficient and I can guarantee you that lack of oxygen attributed to child mortality in some cases. With the money donated to the Welbodi Partnership, through my church, my justgiving campaign and other donations in the UK, we were able to buy 11 oxygen concentrators. Seven of them arrived at the hospital a week and a half ago, the other four are due to arrive in the next two weeks.

The concentrators were sent by DHL to the Lungi airport, which meant that after attempting to get duty free concession from the Ministry (but failing) I headed to the airport with one of the Ministry’s procurement officers. I left home at 6am to be at the hospital by 645am, ready to leave by 7 am to catch the 8 am ferry across. All went well and even the paperwork seemed to be moving along until I was told there was a small problem. Because the shipment had been sitting at the airport for more than a week (because we were waiting for the paperwork at the Ministry!) we were told we had to pay Le 9,000,000!!! That’s almost $2,000. There was no way I was going to pay that. After explaining that the concentrators were for the government-run Children’s Hospital, saying someone should have mentioned that there was a storage fee if a shipment was stored for more than a week, some pleading and a text message to some good friends to ask them to pray, we finally got an okay and the paperwork was (slowly) signed off and the concentrators were released. Time was ticking away and we literally pulled up to the 11 am ferry just before it was set to leave the terminal. It’s always an adventure. We made it back to the hospital around 1 pm and offloaded the concentrators. The next morning Fred (my colleague) and I assembled the concentrators, tested them, marked them and delivered them to the wards. It seriously felt like Christmas. I was so happy. And so was the staff. And before we knew it, the machines were switched on, blowing out oxygen and children were benefiting!

Thank you so much to all who donated. A special thanks to: Kristin Harvey, Rene and Marianne Lako, Verity & Rob Boord, Jennifer Vardy, Alyson Denson and family, Niroshan Nadarajah, Jonathan and Joanna Payne, Emily Spry, Alex Paul, Anne Nesbitt, Maggie Ruth and Baby Jo, Jacco and Marit Groot, Susan Wagler, John Dawson (&Lambton Centre summer camping congregation), Lisa Gibson, Morgen Wilbourne, Sjoerd & Carmen Smits, Middle/High School students at Heritage Baptist Church in Texarkana, Doug Hunter, Gemeente de Wijngaard in Middelburg.

Donations can still be made to my justgiving page and will go directly to Welbodi Partnership to be used in some way to continue improving paediatric care at the hospital in Freetown. (It will not go towards more concentrators, as we now have a sufficient amount!)

http://www.justgiving.com/sandralako

Join our team...

The Welbodi Partnership is currently looking for 2 people to join their team at the Ola During Children's Hospital in Freetown, Sierra Leone as early as July 2011. If you are a doctor, nurse or healthcare manager and interested in volunteering with Welbodi for a year to help improve paediatric care in Sierra Leone, please apply! Not only will you be able to experience healthcare in a developing world, you will also be amazed by the beauty of Sierra Leone - both its people and its beaches are amazing.

Come for a year and make a difference at the Children's Hospital.

For more information go to the following pages:

Information for Healthcare managers

Information for Healthcare professionals (doctors and nurses)

Life-saving blood...

While driving past an NGO hospital last week a friend read out a sign painted on the hospital wall stating that patients need to come with their own blood donors. He thought that was very odd but having been here for years it didn’t seem strange to me. I suppose in the developed world, one would not see such a sign.

Every day children come to the hospital with severe anemia, mostly due to malaria. So, not only do they need to receive anti-malarial medication, they often need blood transfusions as well. Unfortunately it can take up to hours if not days for some of the children to receive blood.
The reason for this is that the blood bank runs on a donor replacement system.

Basically, a family member needs to donate a unit of blood to the blood bank in exchange for a unit of screened blood that is stored in the fridge, which will go directly to the patient. Meanwhile the blood donated by the family member will be screened and if uninfected, it is stored in the fridge and used for a patient needing blood at a later time. It sounds simple but unfortunately in practice, the system does not always work. The main problem is that there is often no family member willing to donate; either no one but the mother is around or relatives do not want to donate. And for some reason the blood bank often refuses to take blood from the mothers.

I do not know why, but in general Sierra Leoneans do not like to donate blood. They either assume that by donating they will get infected with something, or are worried about the HIV screen or various other things. This is a problem because it means a child will not receive blood from the bank because the unit taken out is not going to be replaced. And, in all fairness to the blood bank, if this happens too often the blood bank will be depleted.

I have seen in the Emergency Room and ICU countless children in urgent need of blood. Children literally come in with a hemoglobin as low as 1 or 2 g/dL. Some of these children will die if they don’t receive blood within the first hour. It is for these cases that I will take the child’s blood sample and blood request form to the blood bank and ask for a unit from the screened stock, explaining how critically ill the child is. I do end up getting the blood but not without hesitation. And in all fairness, I totally understand the concern because the more we make exceptions, the more relatives will refrain from donating, assuming we will arrange for them to get blood without having to replace it. This is obviously not sustainable.

In December I was asking for blood so often that I decided it was time to replace some of the blood myself. It was time to donate. So, together with Shona (VSO doctor) we headed to the blood bank on a Friday afternoon after lunch thinking we would be in and out in no time. I should have known better. Although it took a while, I have to say we had an interesting experience.

We wanted the technician to go through the usual procedure to make sure we were fit to donate so he proceeded to check our hemoglobin with the Hemocue. Unfortunately it was not working. He pulled out a color card, which literally was a piece of paper with various shades of red painted on it. I questioned this method and suggested he use the centrifuge for a spun hematocrit. We were rather unfortunate once again as the blood spilled out of the capillary tubes while spinning in the centrifuge. What are the odds? Since I had recently had my blood checked at home, I knew my hemoglobin was okay and we decided to go ahead with the donation.

After the blood grouping, we reclined on the two makeshift beds and got as comfortable as we could knowing a large bore needle was about to be put into our veins. We were more at ease when the technician started playing Christmas tunes from his cell phone. He inserted the needle with ease and it was amazing to see my blood flowing into a blood bag, knowing that it could potentially save a child’s life. It felt incredible to be able to help in such a tangible way and be a part of a child’s healing process. It also made me feel good to know I was giving a unit to the blood bank rather than just taking.

I later learned that my blood had been given to two different children and although I don’t know who they are or what the outcomes were, I know that I helped those children. I will definitely donate as often as I can at Children’s and I definitely recommend that people come to the hospital to donate blood. It is a very worthy cause. Seriously, if you come and donate let me know and I’ll buy you a coke while you recover. And, if you’re not in Sierra Leone, donate at your local blood bank. A unit of blood can impact someone’s life. It can mean the difference between life and death.

First posted @ http://blogs.bmj.com/bmj/2011/02/11/sandra-lako-life-saving-blood/

A unique Christmas gift...

Do you want to give something unique this Christmas?

How about giving Oxygen?

Last Christmas I raised $5000 for a water well in Ethiopia. With your help that was possible. This year I am raising money for oxygen concentrators for the Children's Hospital in Sierra Leone. Can you help me again?

Watch the video and then go to: http://www.justgiving.com/sandralako

MERRY CHRISTMAS.

First Journal Club at the Children's Hospital...

Today was the launch of the journal club at the Ola During Children’s Hospital. Two professors, seven national doctors and three expatriate doctors sat together in an office for the first meeting of its kind.

The journal club was launched as a part of the postgraduate training program in pediatrics that will hopefully kick off in early 2011 (more on this soon). Similar meetings held in the hospital or soon to be held include the morbidity and mortality review, the tutorial topics, lectures, grand rounds and the perinatal meeting. The momentum for an academic atmosphere is exciting.

The journal article chosen for today’s event was published a mere three weeks ago in the Lancet and depicts a trial comparing intravenous artesunate versus the gold standard of intravenous quinine for the treatment of severe malaria in children. This is a very relevant topic in a country where malaria is endemic. Malaria leads to a high number of hospital admissions and contributes greatly to the death rate in children younger than 5 years. To give you an idea, in October 466 out of 981 new admissions were diagnosed with severe malaria (not all laboratory confirmed) and 45% of the total hospital deaths were attributed to severe malaria.

One of the national doctors gave an excellent summary of the article including the methods, results and discussion points. His summary formed the basis for a discussion by the professor on the importance of criticizing such studies – pointing out both the positive and negative aspects of the trial. As this was the first time to evaluate such trials, she further discussed the research process and involvement of various players in research.

We then moved on to the application of the discussion points to clinical practice in the hospital. This to me is one of the most important parts of these meetings. Yes, it is good to discuss trials and outcomes and point out whether or not the trial was performed well but in the end one needs to analyze whether or not clinical practice is evidence based and whether or not it needs to be adapted.

The outcome of this trial is that intravenous artesunate is superior to intravenous quinine in the treatment of severe malaria with artesunate substantially reducing the mortality rate in children. Artesunate is said to be simple, safe and effective.

This sounds good and it seems like the best thing to do would be to switch to using intravenous artesunate in the hospital, however, in a place where artesunate is not affordable and scarcely available this is not a sustainable treatment option. So, we have to look at what we can do, which is make sure our use of quinine to treat severe malaria is optimal. You see, when reading the article I was reminded that the preferred way of administering quinine is intravenous rather than intramuscular and 8 hourly instead of 12 hourly. So I brought this up. This of course led to an interesting discussion and critical look at our treatment choice.

Yes, the doctors know intravenous is better than intramuscular, however, for various reasons (poor monitoring of a child’s blood sugar, poor monitoring of infusion rates, lack of fluids and other resources, lack of nursing staff) they choose to prescribe it intramuscularly arguing that it is safer in most cases and generally as effective. Of course, they give this 12 hourly to decrease the chance of an injection abscess. We discussed the issue and went back and forth, deciding to consult the guidelines. Seeing as the World Health Organization recently published the 2010 Treatment Guidelines for Malaria it seemed like a good place to look. So, based on the information and the high cost of intravenous artesunate (although a good cost analysis should be done of iv quinine versus iv artesunate), the patients will continue to receive quinine, but 8 hourly. When possible they will receive it as an infusion rather than as an intramuscular injection but in reality we will have to see how that works.

All in all I would say that the journal club was a success leading to a critical look at malaria treatment at the Children’s Hospital, which will hopefully lead to better outcomes for children coming in with severe malaria. This was a good start to the journal club.

As posted on the BMJ website: http://blogs.bmj.com/bmj/2010/12/13/sandra-lako-journal-club/

Prospects and challenges of an x ray department...

The Ola During Children’s Hospital is 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 Children’s Hospital. Can you imagine a hospital without x ray services?

Presently children need to travel across town to Connaught Hospital for x rays. This is often a three-day process. The child receives an x ray request form on day 1, goes to Connaught very early in the morning on day 2, and goes back to Connaught on day 3to pick up the x ray and report. This is an obvious delay in the diagnostic process. Also, for very sick children, having to travel across town is simply not possible because there is no way to transport them safely, especially if they are in need of oxygen. Clearly, there is a need for a functioning x ray unit.

The new x ray unit will complement the ultrasound services in forming the radiology department shared between Ola During Children’s Hospital and Princess Christian Maternity Center.

In June the Ministry of Health and Sanitation promised to deliver an x ray unit to the hospitals. 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. The next step: assembling/installing the unit. This took longer than expected, but was a success. The next hurdle was to connect the new processor to the water supply. Unfortunately this proved too difficult, in part due to lack of high quality plumbing but also due to the poor water supply at the hospital. It was decided that for now the old processor would be used until the water situation has improved.

Now that the x ray unit is ready for use, the department is faced with the biggest challenge yet, namely, the lack of x ray films and developer and fixer solutions. The government supplied central medical store is in short supply and it is uncertain when or where the next stock will come from. To further compound the problem, Connaught hospital can now only give 10 children access to free x rays per day due to their limited supplies. Of course, one can still pay for an x ray but the majority of the families do not have the Le 30,000 – Le 40,000 ($8-10) needed for one x ray. Yesterday there were three children in the feeding center needing chest x rays who have already made the early 5 am trip to Connaught two days in a row and been turned back because the 10 slots for free x-rays for the day were already used up. This is a bit of a dilemma.

So, now I sit here wondering where the supplies will come from and how this department will be sustainable? Will the Ministry step in and be able to help with a constant supply? Will the hospital need to find funds to buy films and solutions from Guinea or possibly even the UK or USA? Will the hospital be able to provide free x ray services for inpatients or will it be on a cost-recovery basis in order to generate income to purchase more supplies? And what is the role of the non-governmental organizations (NGOs) in this? If the NGOs help with the initial supply, how long must they continue supplying and who will sustain this? It is a dilemma and I am afraid I do not have a solution.

So, if anyone does have a solution, feel free to comment. And if anyone out there has a never ending supply of x ray films and solutions that they could deliver to the door of the hospital free of charge, you would be more than welcome to do so.

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 accreditation as a teaching hospital. Ola During will move forward one step at a time…

First posted on BMJ

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.

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.

Namina's story...

Three and a half year old Namina and her mother arrived at the Mercy Ships outpatient clinic for children on January 21, 2009 after being referred from the Lungi Government Hospital following a one month admission there. She had been referred to the Mercy Ships clinic for surgical reconstruction of her face.

Namina had been inflicted with a devastating disease known as “cancrum oris” or “noma”. This disease is rightly referred to as the “face of poverty”, affecting the poorest of the poor. At the age of 3 ½ years, Namina weighed only 10 kilograms; her malnutrition making her more susceptible to infection. It started as a small lesion in her mouth but soon spread and turned into a gangrenous flesh eating disease causing massive destruction of her facial tissues. With a high mortality rate, few people survive. Yet Namina was a survivor, but it left her face disfigured.

The initial thought was to send her back to Lungi because this was not a condition that could be treated in the clinic; reconstructive surgery was not available. However, within minutes this little girl captured the hearts of those working in the clinic. The doctor went ahead and examined Namina to see the extent of the damage. It was bad. Sure enough there was a gaping hole in the left side of her face. It was a hideous sight. It was heartbreaking. However, Namina had already proved she was a fighter. She had survived the intial infection and it was now our job to make sure she continued to improve. Not only did she have a disfigured face, she also suffered from malnutrition and malaria. Immediately, the staff provided the necessary medications and nutritional support needed, as well as the wound care that was required. It was obvious that it would take months for the wound to heal enough so that reconstructive surgery could be considered. The follow-up was intense.

For weeks Namina and her mother came to the clinic for wound care; in the beginning as often as three to four times a week. The wound care was often a painful process in which the wound was thoroughly flushed and cleaned with saline solution and then dressed with sterile gauze. This often brought tears to Namina’s eyes, but once the dressing change was over, she was ready to play again and always looked forward to choosing a toy from the toy box. Nutritional support was given to Namina in the form of a high protein drink and as time went by, progress could be seen. Not only was the wound starting to heal, but Namina was becoming stronger and healthier.

After five months, Namina has turned into a vibrant little girl. She still has a small hole in the left side of her face, but it has healed considerably. Namina is happy. And both her mother and the staff of the outpatient clinic are very pleased with the results. It is now time to move on to the next step and look into possibilities for reconstructive surgery. The process is not over yet, but Namina has come a long way.

Other posts related to Namina can be found here and here.

Permission from Namina's mother was given for the publishing of her story.