Kambia Government Hospital, Sierra Leone, January – May 2009

We had been looking for job opportunities in Africa when we spotted the recruitment advertisement on a doctors’ website. Sierra Leone. We hadn’t considered the possibility of spending half a year in a rural hospital in a country known mostly for its recent horrific civil war. However, the challenge was attractive. By January 2008 we had decided that after completing our Foundation training, Sierra Leone would indeed be our destination as doctors.

We spent most of 2008 reading about the country, talking to people who had worked there and fundraising. In the autumn we attended the invaluable Diploma in Tropical Medicine and Hygiene at Liverpool. Here time and time again Sierra Leone is highlighted by lecturers – the only country where diseases like yellow fever and onchocerciasis are still significant problems, where infant mortality and maternal mortality are amongst the highest in the world. According to WHO statistics, 25% of Sierra Leonean children die before the age of five. The figures we had read about did not seem real until we actually started working in Kambia.

We arrived in Sierra Leone on 12th January 2009. The four-hour drive from Freetown in a UNICEF-donated Land Rover is bumpy and dusty. Situated in the North, close to the Guinea border and destroyed during the civil war, Kambia Government Hospital was rebuilt in 2002 with funds from the European Union. The hospital has about 60 beds and is meant to provide services for the whole of Kambia District – a population of over 300,000. However, healthcare in Sierra Leone is not free, fuel is more expensive than in the UK and the roads are atrocious. All these factors mean that people do not readily travel to hospital for treatment. Hence, the hospital was not busy in terms of numbers but almost all the inpatients we saw were critically ill and had usually been unwell for long periods before making their way to hospital as a last resort. We worked together with a local medical officer, Dr Davis Sessay, and an experienced Community Health Officer, Mohammed Kamara. Except for four trained nurses, most of the other staff at the hospital are untrained volunteers. The hospital lacks running water and electricity is very rarely available. The pharmacy is reasonably stocked with basic drugs and medical supplies, but patients have to pay for each individual item, even in dire emergencies.

Obstetrics is a large part of our work. Women in Sierra Leone usually give birth at home with the help of traditional birth attendants. Most of the women we saw had come in after being in labour for two or three days or because they had had a complication such as a fit or severe bleeding at home. We saw several cases of eclampsia, cerebral malaria in pregnancy and obstructed labour. Fortunately, quinine, magnesium sulphate and oxytocin are readily available. Eclampsia – a severe disease associated with fitting and high blood pressure in pregnancy, is now rare in the UK. However, in Sierra Leone most women are unable to access routine antenatal check-ups and simple treatment for high blood pressure is not readily available.

At the same time, it is common to become pregnant at a young age – many girls have been malnourished during childhood and the pelvis has not had time to develop fully. These women often need emergency Caesarean sections to deliver the baby. At Kambia there is a basic operating theatre and one local medical officer who is experienced in performing Caesarean Sections. A timely operation often saved the life of a woman who had either been bleeding heavily or had been in labour for several days. However, the mortality rate associated with surgery is high and wound infections are almost universal. We suspect this is due to a combination of poor surgical technique, inadequate asepsis, the inability of the patient to afford antibiotics and poor nutritional and psychological status of the women (especially, and sadly not uncommonly, if the baby had not survived).

Indeed the stillbirth and neonatal mortality rates are very high. We became much more confident in resuscitating newborn babies with a simple bag and mask – skills that we had been taught during our time at Liverpool. This is one aspect of our work that was at times distressing, but also sometimes most rewarding. However, neither of us are trained surgeons, and whether or not we would perform an emergency Caesarean section if the need arose was one question which we had thought about at great length before we had set off for Kambia. Current WHO guidelines for low-resource settings advocate emergency Caesarean sections only in circumstances where the mother’s life is in danger and not solely on the grounds of foetal distress. We were faced with two occasions when the local medical officer was away and women were brought in with an obstetric emergency. The first woman arrived on a Friday with a history of having bled heavily. We had no way of confirming why she had bled, but clinically we suspected placenta praevia (a condition where the placenta lies low in the uterus, thus obstructing the birth canal, which is usually diagnosed using an ultrasound scan). However, the bleeding had settled, the diagnosis was uncertain, and we had previously never performed major surgery – so we decided to watch and wait. On Monday however, the lady began to bleed profusely. The blood bank supply was exhausted and the medical officer had not yet returned. Despite our efforts to resuscitate her, she passed away within a few hours. This experience, for us, was humbling. In the UK it would be unacceptable for a young pregnant woman to bleed to death simply due to lack of resources. The hospital staff, on the other hand, were accustomed to almost routine maternal deaths.

However, we were gaining experience rapidly and on a subsequent occasion, faced with a similar scenario, we mobilised the hospital staff for an early and successful Caesarean Section. Guided by experienced local theatre staff, one of us held the scalpel and delivered a pair of twins while the other – with the help of eager students – resuscitated the twins. The occasional happy outcome is uplifting for all the staff as well as of course for the family.

In the adult and children’s wards malaria, typhoid and tuberculosis were amongst the commonest diseases. In Kambia, we experienced first hand the effects of the Global Fund initiative to eradicate diseases such as Malaria, TB and AIDS. Good and effective malaria treatment is readily available, while the whole treatment course for patients diagnosed with TB or HIV infection is entirely free. As a result we found that paradoxically, patients with HIV – often shunned by family and society – in fact received preferentially better care in hospital than other patients. At the same time children with suspected malaria, who often came in unconscious with the cerebral form of the disease, recovered rapidly with readily available drugs such as quinine and artemisinin-combination therapy. In contrast however, many adults and children came in with serious surgical complications such as bowel obstruction or perforation – in many cases resulting from prolonged typhoid fever. Complications usually arose due to the initial phase of the disease going untreated. We referred some patients with such surgical emergencies to Freetown where better facilities were available. However this is only possible in the few cases where the patient is either well enough to travel or could afford the cost of the journey. In any case, these patients rarely survived their illness.

Every time a woman or a child died in hospital we were struck by how easily it is accepted by the relatives - as if it is an expected and routine part of life for a woman to lose a child or to die in childbirth. Whilst for us, the feeling of knowing what to do, yet being unable to do it is often demoralising as well as humbling. Our short stay gave us an invaluable insight into how lives are lived in a world very different to the one we are accustomed to and how helpless we as individuals can be despite all the training and education we may have received. Nevertheless, despite the obvious suffering, there is never a shortage of smiling faces and cheering children following us wherever we went. We returned from Sierra Leone richer in experience and with the feeling that we had left behind a number of good friends. Our five-month stay may not have been long enough to make a lasting difference to the workings of the hospital, but we now feel better and more realistically prepared for more long-term work in a similar resource-poor setting. Perhaps it might be Sierra Leone again.

We are grateful for the support we received from The Kambia Appeal, The Cheltenham Ladies’ College Guild Fund, Bassett Road Surgery, The White House Surgery, students of Edinburgh University and many friends and family who helped us prepare for our five months in Kambia. We hope that reading about our experiences will encourage others to learn more about Sierra Leone and its people.

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