"Yes, but aside from the hernia..."

6.29am. Hear a knock at the door. Greeted by a nursing student who hands me the chart of a new patient on the maternity ward. ‘Sister sent this chart for you to see the patient”. Try to establish from the student how unwell the patient is, whether any vital signs have been recorded and whether I can finish brushing my teeth. Student insists she is only the messenger and that ‘Sister said you should come’. Decide it’s too early in the day to give my nursing triage tutorial on the doorstep and head to maternity. Thankfully, the woman who is 30 weeks pregnant is not too unwell but has been feeling progressively worse with fevers, ‘generalised body pain’ (a favourite symptom which features in most patient’s complaints) and headache. I organise our limited panel of blood tests (blood count and a malaria test), commence her on treatment for malaria, advise the student to monitor her observations and after examining her, reassure the expectant mother that her baby’s heart rate is healthy.  

8.24am. Drop into lab to check on the progress of the arrival of HIV tests as since the previous night current stocks have reduced to zero preventing any testing or blood transfusion.

8.30am. Arrive at the outpatient department and catch up with the other junior doctor from the UK.

8.43am. Telephone medical superintendant to see if we should start the ward round without him. Informed that (at short notice) he and the sole midwife for the hospital have been called to attend a training workshop in Bo (Sierra Leone’s 2^nd city) for 3 days. Advised to start ward round without him and continue for next 3 days.

8.57am. Maternity ward. Thankfully, no women are currently in labour and the woman from earlier is starting to look brighter.  Good news from a lady who had a caesarean, whose scar, which was infected, has now fully healed and her baby who weighed a meagre 1.7Kg at birth has now breached the 2Kg mark and is breast feeding well.

9.40am. Children’s ward. Together with the other doctor, weigh up our options for a child admitted with sever malaria and anaemia who needs a blood transfusion. Despite explaining to the family that we cannot offer safe blood transfusion currently until the HIV tests arrive, they feel there is no option for them to travel to another hospital. Telephone the lab again. Informed that someone is picking the tests up from Kenema as we speak. Maintain the child with fluids and continue treatment in the interim. Continue to see the remaining patients on the ward and also have to give a lengthy reassurance to a mother whose child is happily running wild around the ward that, unlike the first child, her little boy would not benefit from a blood transfusion.

10.32am. Start to get exasperated with patient on Men’s medical ward, whose sole response to questions in any language is that he has a hernia. On examination although he does in fact have a small reducible unproblematic hernia, more worryingly his heart rate is twice as high as normal, he is incredibly dehydrated, struggling to breath, anaemic and in heart failure. Try to prevent outward signs of further infuriation with relatives who, despite the obvious visual malady of his critical condition, also voice the only problem to be ‘hernia’ for 10 years(!) and request that we schedule surgery. Explain that his hernia is not currently the most pressing concern and we need to initiate emergency medical treatment.  

10.58am. Start seeing outpatients. Usual mix of patients; one group of whom are very well and most of my time is spent convincing them that they do not need injections or lab tests despite their insistent requests, or trying to advise both patients and nursing students that malaria is not a symptom but an illness. The second group of patients are those whom appear pleasantly unaware of quite how unwell they are and most of my time is spent negotiating with them and their relatives on the need to be admitted to hospital. Admit 3 patients to the ward; a 12 year old boy with a massively swollen abdomen, tense with accumulated fluid now making it difficult for him to lie flat or breathe, an infant with malnutrition and malaria, and one young lady, very unwell with suspected TB.

12.14pm Check in on the lab to find out that happily the HIV tests have arrived enabling blood transfusion to be organised.

2.47pm. Breathe a momentary sigh of relief as the last outpatient card on my desk is duly handed back to their owner and they are instructed towards the pharmacy. Try to not look disheartened/anxious/confused when 30 seconds later, two members of the Sierra Leone army walk into my office and request for me to see one additional outpatient who, unfortunately for him, has a rather unequivocal diagnosis; very unusually, they have brought me a corpse. Thankfully they do not have expectations of resurrection but simply need a medical doctor to confirm that the person was, in fact, deceased. For a moment I think they are going to bring him straight in to the consulting room but they agree to take their vehicle and the body round to the room we use as a temporary mortuary next to the men’s medical ward to be examined.

3.12pm. Conduct a superficial scan of the wards and check on the earlier admissions.

4.00pm. Walk down to the nursing school classroom to teach the final year nursing students on (ironically) safe blood transfusion, including the prerequisites tests required and a separate lecture on the safe use of antibiotics. Correct various assumptions about the role of antibiotics. The prize for most unusual applications goes to one female student who is confident that antibiotics should be taken every month after a woman has her menstrual period in order to ‘cleanse her’.  I wonder why we have problems with antibiotic resistance…

6.04pm. Called to the delivery room to assess a woman in labour.  

6.24pm. Telephone my Nan in the UK to wish her well for her cataract operation.

6.33pm. Supervise the delivery of a new healthy baby boy. Almost miss the key moment when his shoulder get stuck due to the above telephone call (whoops). Nevertheless, new mother and child do very well.     

10.57pm. Called to Men’s ward to assist the other doctor with a young man admitted vomiting large amounts of blood due to a suspected bleed inside his stomach. Manage to place a line in his arm to give him intravenous fluids and, after establishing which family members had a compatible blood group, several units of donated blood.

2 am. Called back to Men’s ward. Greeted by a policeman in the middle of the ward and a semi-conscious patient at the other end of the ward with a trail of blood connecting the two. Informed by policemen that man was seen drinking excessively earlier, then possibly got into a fight with a ‘friend’ and was found semi-rousable beside the main road with blood seeping from the back of his head. Begin to assess the patient who becomes more alert, starts thrashing violently, swears at everyone on the ward and then vomits profusely. Thank the policeman for his kind delivery and begin to think I have been transported back to a certain south east London A&E where I treated not dissimilar patients. Once he is slightly more amenable to assistance I give him some intravenous fluids, clean his head wound and place a temporary dressing. Realise that the plastic apron has not been especially effective at protecting my clothes and shoes from the patient’s bodily fluids.

2.38am. Return to house. Wash blood and non-descript bodily fluids off clothes and shoes and climb back in to bed.

Shameless advert: If this sounds like fun, the hospital is about to begin searching for and recruiting medical doctors. Details to follow soon. Please note, (naturally) the post will not be compliant with the European Working Time Directive.

Update May 2014. Please see links below for details of medical post.

 ·         http://healthmattersinsegbwema.blogspot.com/p/medical-opportunity-advertisement.html

·         http://www.workingabroad.com/database/medical-doctor-nixon-memorial-hospital-segbwema-sierra-leone

Tarmac & Progress

View looking down to Segbwema from outside the hospital
in  2014

View looking down to Segbwema from outside the hospital
in  2010

 For the first time in Segbwema’s recent history I was able to walk down to the town tonight (for the necessary therapeutic cold beer) on a smooth tarmac road. After the months of construction and dust the highway connecting Kenema and Segbwema is almost finished. In a place where progress since the end of its civil conflict can often seem agonisingly slow, such pivotal developments in infrastructure are worthy of celebration. Improved access to Kenema, Sierra Leone’s 3^rd city and on to Freetown should optimistically act as a catalyst for development in the area, improving trade, increasing the availability of services and supplies and will hopefully make the town a more appealing place to live and work, attracting future healthcare workers.  Whilst one of the downsides of increased human travel is certainly highlighted by this week’s Ebola virus outbreak which, according to the World Service, has now possibly edged across from Guinea and Liberia into Sierra Leone, improved connectivity with the outside world should be fruitful for Segbwema and the hospital. My only other lingering doubt is whether the number of road accidents caused by the poor visibility and uneven gravel will be replaced by road accidents caused by motorists over-zealously increasing their speed on the novel flat black surface; only time will tell.

This morning the Anti-Corruption Commission held a workshop for staff and students at the hospital. Sadly corruption remains endemic in Sierra Leone (as no doubt it does in many other countries) extending from million dollar under the table deals at the top of the tree, right down to the grass roots of dishonest primary school teachers expecting a few thousand leones (£1-10) from their pupils to ensure they get the right marks in their exams. Realistically it may take a decade, or more likely a generation, for corruption to be removed from Sierra Leone’s way of life. Nevertheless this transition has to start somewhere and the workshop and unexpectedly uplifting talks this morning focusing on the need for positive role models and prevention of corruption seemed a reasonable place to begin.

When I think about Sierra Leone’s recovery and development I remember a patient I once discussed with a neurology consultant as a student. The patient was an 18 year old who had suffered a traumatic brain injury when he had driven home intoxicated with drugs and alcohol and had a head-on collision with a truck. When I first met him he had been in a rehabilitation hospital for 6 months gradually re-learning how to speak and how to walk. The consultant made the salient point that in addition to the challenges faced by having to regain the basic human functions of communicating and moving, his path to integration back into society was made more challenging by his starting point. He was not a high flyer from a supportive family but had dropped out of school at 16 with no qualifications, been unemployed for 2 years prior to the injury and been struggling with drink and drug problems.  Had he not had the serious car accident, his path to a productive independent adult life would still have been challenging; with the brain injury the magnitude of task increased several fold.  Sierra Leone was certainly no high-flying middle class patient with a supportive family when civil war broke out. Decades of one party rule, corruption, political mismanagement and rampant borrowing had resulted in a slow grinding poverty with erosion of education and economic growth. Whilst I’m sure that if integrity was a value slightly more endemic through both the governmental and private sectors certain gains could be achieved more quickly,  in many ways it is perhaps understandable that some areas of development are not as far forward as we would hope or expect giving their starting point.

Another first this month in Segbwema’s recent history was having a hospital staffed by a grand total of four doctors (possibly a record since the hospital re-opened) thanks to a very productive 3 week visit from a semi-retired GP and his wife. He, like me, had visited the hospital 3 years ago and it was heartening to hear him talk and reiterate the developments that had occurred since then. From surgery happening in a side room between two wards to a rehabilitated and functioning operating theatre, from muddled notes to organised patient charts and from often scantily filled medical cupboards to a well stocked pharmacy. Undeniably, the difficulties and challenges the hospital and community face remain huge and often seem insurmountable. The daily grind can make it hard to appreciate the long term progress that has occurred but perhaps it is important to stand back once in a while to see that gradual positive shift of circumstances and situations. 

On the gardening front the quick grow lettuce leaves were looking very promising until their progress was permanently halted when they were squashed by the bottom of a certain 2 year old girl who was playing exuberantly with a toy car outside the front door. I’m sure there’s a metaphor there somewhere or perhaps I should simply give up on home grown produce.

Tears Over Ten Pounds

Although I had scribbled down a few thoughts to write here before we left Sierra Leone for a short break to the UK in January, I somehow felt I would be committing literary fraud had I uploaded such ramblings via an ultra-fast broadband connection in London.  Now back in Segbwema, sitting with my head torch and the frustration of watching the percentage on my laptop battery rapidly reduce as the mobile internet modem repeatedly flashes ‘unable to connect’, I’m beginning to think perhaps my need for authenticity was over-valued.

Having returned less than 2 weeks ago, the memory of sitting in a pub near London Bridge certainly feels more than a 6 hour flight away. Incidentally the said pub was the place where some of the events of the past 6 months caught up with me and I did the almost inexcusable act for a (relatively) grown man of leaking a tear or two in public. The barman may have ascribed my sadness to the realisation that a ten pound note is no longer deemed sufficient funds to guarantee the purchase of two pints in London, and whilst this almost constitutes a valid reason for not returning to the UK, my thoughts were elsewhere, with a patient I hoped I could have done more for. Still I’m sure we proved a talking point for the couple on an awkward first date next to us.

Whilst there were many welcoming familiar faces to return to at the hospital, sadly one of those that was not among them was Evelyn, the lady we were caring for on the TB ward, who, after several months of ups and downs (and breaks in her TB medication) had sadly passed away.  Another loss to report, although of several thousand magnitudes less significance, is that of the final tomato plant grown from seed in August which finally succumbed to the January heat. Perhaps if I was a detached journalist I’d feel comfortable making some comparison about the odds being stacked against both the tomatoes and my patient in a difficult harsh environment, but when that patient is also a person whose daily interactions and exchanges considerably brightened up your day, such comparisons seem coarse and inappropriate for a very human situation. Initially I thought about cutting my losses altogether with my micro- agricultural endeavours, or else trying to grow something slightly more instantaneous like cress. However, after remembering that I’ve never been one to see the point of cress, I’ve settled on quick grow lettuce as the middle way. (Updates to follow…)

Despite perhaps some of the aforementioned gloomy news there are signs of progress at the hospital and much to be looking forward to. The hospital is functioning reasonably with access to essential medicines and happily another junior doctor with an interest in paediatrics arrived with us at the end of January, increasing our medical staffing by 50%! The maternity ward is reassuringly full and the proportion of women with new babies in cots at the end of their beds is the highest I’ve ever seen, including twins that arrived a couple of nights ago. The number of children at Janna’s impromptu  ‘door step’ school seems to be growing by the day (sometimes it can be a challenge to get to the door as you have to wade through a mass of young bodies lying drawing on the floor) and the chunky chalks we brought back have been an instant success with the floor and walls outside our house now being covered with colourful letters, numbers and pictures which certainly makes for a prettier sight than the remnants of the rebel's ‘RUF’ graffiti that despite being over 10 years old, still remain.

Now all we need is that broadband connection…..

20% Mechanically Separated Turkey (Happy Christmas)

“26% turkey, 20% mechanically separated turkey”; such percentages on a tin of meat leave a lot to the imagination and the words ‘mechanically separated’ do little to tempt the taste buds. However, a can of ‘Ye Olde Oak Turkey Roll’ was the best of a mixed bunch of traditional festive offerings in the Kenema supermarket. We did splash out on a tin of Danish ham with a slightly more reassuring meat content of 84%. Once we threw together a few handmade Christmas decorations and crafted a cardboard tree from an old drinks box, our festive plans were complete. Whilst there may be many things we shall miss this Christmas, the simplicity of our preparations and absence of anything resembling a crowded shopping mall is unquestionably refreshing.  

The hospital has sympathetically quietened a little this week and we’ve closed the outpatient department from today through to Boxing Day.  Nevertheless, as with any hospital there are still enough emergencies to keep us in business; unfortunately the increased number of festive travellers and some dangerous road conditions created due to excessive dust and gravel on the half -finished Segbwema –Kenema road have combined to result in a worryingly high number of accidents.

In some ways it has been difficult to get into the festive spirit, but I felt the Christmas atmosphere arrive last week courtesy of some impromptu music in the hospital to help calm a nervous patient.  A young girl was having a procedure performed under local anaesthetic in the operating theatre and had started to become increasingly anxious towards the final stages of her surgery. Fortunately I had my IPod in my bag and we decided to put on some music to help her relax. After a quick search for a ‘Merry Xmas’ album, a stillness descended and we all enjoyed a serene moment of calm and quiet as voices singing ‘Silent Night’ filled the room.

I popped down to the TB ward this morning to see Evelyn and her gang to deliver a food package for the next few days including some fresh beef from the market. Incidentally, we saw the cow from which the meat came being led down through town as we sat having a drink at Victor's bar last night. Although perhaps not quite matured for 21 days, at least we knew it was fresh! (It appears that I’ve come a long way from my vegetarian years as I certainly enjoyed the portion of Daisy the cow which we had for our lunch).

After we re-opened the hospital library we set the student nurses an essay competition on “strategies to reduce the burden of maternal death in their local community” to encourage them to do some research.  Last week we happily began to peruse their entries and I shall end this Christmas Eve by sharing a few of their words of wisdom.  

On the importance of punishing those involved in sex crimes:

“As the saying goes, when the first frog falls into the pit, the others behind will take caution.” (MS)

On the need to work together on health interventions:

“In order to achieve (a reduction in maternal mortality) there must be collective cooperation. That is pregnant women, husbands, neighbours, the youth, the elderly, health workers, drivers and government workers each have a role to play. Their joint contribution in one way or another will help to save lives”. (SK)

On the importance of family planning:

“A father should be encouraged to remember that the community will judge him as much by the health of his children as the number of his children.” (AM)

Happy Christmas!

Magnesium Sulphate, Coke and Other Drugs

Thanks to a generous grant from a UK charity we found ourselves in Freetown a few weeks ago on a ‘drug run’ aiming to initiate a sustainable supply of medicines for the hospital. With 48 million Leones (about £8000) next to me in plastic bags, sitting in a wholesale pharmacy surrounded by packets and plastic containers of several decades of pharmaceutical development, I felt like a child in a toy shop with a year’s worth of pocket money to spend supplemented by a large Christmas bonus. Naturally, as is the way in Africa, it wasn’t quite as simple as turning up with our shopping list, and a number of items on our newly developed formulary were very difficult to locate in Freetown’s almost impenetrable congestion. Adult naso-gastric tubes, thiazide diuretics and blood transfusion bags appeared to be like gold dust. Efforts to secure 100 vials of magnesium sulphate (the precious drug needed to treat seizures in pregnancy that was unavailable on one of my recent night time visits to the ward) involved a “BBC apprentice” style mission consisting of negotiating with the Women’s Centre in Freetown to find their supplier and then abandoning the vehicle and dashing through the stand-still traffic to meet him in a central location for exchange of goods and money before we left town. 

 At some points when rushing around in the suffocating hustle of horns and swarming masses of people that comprise Sierra Leone’s capital city, I wished I had my stethoscope with me. Fortunately, this desire did not come from an unseen medical emergency, but from a craving for that moment of quiet and solitude you get from closing off the outside world as you place a stethoscope in your ears. Perhaps I am not alone in this, but not uncommonly I leave my stethoscope on a patient’s chest for a few seconds longer than is clinically really necessary, just to enjoy that moment of uninterrupted calm, with only the “lub-dup” of the patient’s heart in my ears; in amongst the chaos of hospital life it is possibly the only time when you are rarely interrupted.

Although it has been a significant boost to know that we now have most of the core essential medicines available, the art of medicine is often more complex than finding the right combination of pills. An older woman on the female ward was becoming what one would unkindly refer to as a “heart sink” patient. Each day the observation chart would show everything to be normal, examination was always unremarkable and yet each day she would have a new complaint to tell me about. Although mental health and psychological support are spoken of little here, it was clear that some of her problems may be related to a low mood, not helped by an absence of any visits from family members. I was doubtful that anything from the pharmacy would improve her list of ailments. After a few days of her not leaving the ward or getting out of bed, I decided to bargain with her that if she had a walk outside I would find her a can of coke. ‘You’re all talk and no action pumwee (white person), ’ was her vague reply. However, I was true to my word and went and found a couple of cans of Coca Cola, and she willingly kept up her end of the deal and came and sat with me outside for a drink.  For the first time I saw a glimmer of a smile on her face. In a week that saw me exhausted from not sleeping due to a noisy contractor staying upstairs, half blind from catching a purulent conjunctivitis, and miserable from eating only bread and ‘cheeze balls’ for 5 days after our camping stove malfunctioned and caught fire, I’m not sure whether it was the patient or me who most needed that 10 minute sit on the wall outside the ward in the sunshine with a coke on a Friday morning.

I would be lying if I said that sometimes the daily grind doesn’t get me down and that the tiredness and frustration of seeing the human cost of unmet healthcare need doesn’t upset me, but I know it would be naïve to imagine that I’m the only exhausted worker in the world. This time last year I was working in A&E in London which was an endurance activity in itself. I especially remember a certain sense of despondency on night shifts when colleagues whose shifts started earlier in the day gradually left every couple of hours throughout the night, until 2am when there was only 3 or 4 doctors left working in the department until morning. It wasn’t uncommon, particularly on a Saturday night, for the list of patients on the computer screen waiting to be seen to increase at a faster rate than the team of doctors could cope with, and thus the number of patients breaching the stipulated 4 hour target by the time morning came was sometimes embarrassingly long.  But however bad the night was, there was some comfort in the knowledge that at 8am a healthy brigade of fresh A&E doctors would arrive and within a few hours the department would usually be more respectable; however low you may have felt at 5am, you knew by 10am you’d be at home in bed and someone else would be clearing up the mess. The only difference here is that at 8am nothing changes and there is no cavalry coming over the hill.

Evelyn update: Evelyn came back from the village a couple of weeks ago and so far appears to be making reasonable progress despite the gap in her treatment. Unfortunately she has an ever growing number of patients for company on the TB ward as diagnoses are on the increase, possibly contributed to by problems with continuity of the government’s TB drug supplies.

Tomato update:  Plants are doing ok but since being planted out into old rice bags one or two have fallen by the wayside. Naturally I am suspecting sabotage from my noisy contractor house guest. (Does lack of sleep make you paranoid…?)

To Cut or Not to Cut?

 
As Janna stood over me with a pair of old rusting surgical scissors, previously given to me by a colleague to practice surgical knot tying, I began to consider if, in fact, I really needed a hair cut at all.



The local barber shop

Although I have to confess I have let slip my previous routine of a daily shave before work, my hair was beginning to edge towards a somewhat Neanderthal appearance and I felt both patients and relatives may have a little more confidence in me if I had a trim. I first attempted to have a hair cut not long after we arrived and visited a barber’s shack at the top of the hill outside the hospital gates. The barber’s method of hair dressing was unorthodox to say the least. Instead of using clippers or scissors, he employed an interesting comb-like device into which he placed a razor blade which he used to make repeated small slicing movements hacking away at my hair. After around an hour of painful tugging and the constant feeling that perhaps he hadn’t quite understood what I meant by a ‘tidy up’ I emerged looking probably more dishevelled than I started. Having learnt from this experience, 2 months on I found myself in the Lebanese supermarket in Kenema looking at the two available hair clipper sets; a mains powered one or a slightly cheaper battery powered set.  Anyone that knows my frugal inclination and fondness for a bargain will be unsurprised to hear that I opted for the cheaper version. Predictably, this was the wrong call as when I got back to the hospital I discovered that instead of cutting, the battery powered clippers weakly pulled at the hairs as it glossed over them. And thus I found myself entrusting Janna with the scissors….

Of course in a hospital there are far more serious matters concerning the decision to cut or not. (Incidentally, I am not referring to the widespread practice of an initiation rite performed by secret societies that may affect up to 98% of Sierra Leonean girls and young women; the controversy and depth of secrecy of which means that it is probably appropriate that I only allude to it whilst I reside here).  I am indeed referring to the matter of operations and surgery, which can be a risky business even in the most high tech of healthcare facilities. In my first week here the surgical team performed an operation to the remove a very large football sized fibroid (benign tumour) from a woman. There was much fanfare surrounding this with a line of students queuing up to see the specimen and congratulatory talk of whether this was the biggest fibroid removed in Sierra Leone.  Conversely, there is little excitement or passion for the child slowly dying from preventable anaemia and malnutrition, and there were certainly no trumpets sounding out in celebration after 2 weeks of medical input managed to get a young man with suspected typhoid fever, pulmonary oedema (fluid on the lungs) and kidney failure, a potentially terminal situation, round the corner towards recovery.

Perhaps it is the physical and visceral nature of surgery and operations that maintains the palpable awe that surrounds them and their ability to allow people, whether medical or not, to relate to a visual understanding of the cure of an illness which is seducing. However, one of the most important lessons in any surgical speciality maybe knowing when not to cut; just because something can be done does not mean it should be. Whilst I hope the woman who had the fibroid removed made an informed decision about the possible risks and benefits before choosing to proceed, I imagine there would have been far less back-slapping had a complication arisen, even one requiring relatively simple correctable measures such as oxygen which is not available.

Another increasingly difficult surgical decision concerns whether to carry out a caesarean for a woman in labour. On UK delivery suites there is naturally a relatively low threshold to intervene if there is any suggestion of foetal compromise. However, in rural Sierra Leone, even when accounting for the limitations in how the foetal heart can be monitored, the boundaries are rather different. Subjecting a woman, particularly in her first pregnancy to a caesarean will leave her with a scarred uterus that may well have to endure labour five, six or ten more times, which possibly will occur nowhere near a health facility or near someone trained appropriately to deal with the complications that may arise including rupture of the scar. In addition, the initial operation will have an increased risk of complications due to the very nature of the environment of limited medical resources and expertise that it is taking place in. The consequence of this heightened risk to the mother’s health and life, both in the acute situation and for future pregnancies is that the value placed on trying to save the life of her unborn child through surgical intervention is sadly less than it should have to be.  

Thankfully I have not had too many comments on my new look. At least the difference between a bad haircut and a good hair cut is only 2 weeks; the consequences of an inappropriate operation can be lifelong.

Onc(hocerciasis)ology

When reorganising, de-cob webbing and cleaning the hospital library I pointed to one of the newly labelled sections on cancer and asked one of the first year nursing students, who was helping us, if he knew the meaning of the word “oncology”. Although obviously unsure, to his credit, he gave it some logical thought and said “is it the medical speciality that deals with onchocerciasis?’ (River blindness). Whilst river blindness (a parasitic worm disease transmitted through the bite of black flies)remains endemic in many parts of West Africa, cancer appears something that has little presence both in and out of the hospital. Whilst having the potential to affect anyone, cancer is predominantly a disease of older people and the life expectancy of 48 years in Sierra Leone undoubtedly limits the target age group for many forms of malignancy. Even for those unfortunate enough to be afflicted by the disease, without the facilities of CT scans and laboratories equipped to comprehensively examine tissue biopsies, a definitive diagnosis often remains elusive.

Unlike the valuable “2 week rule” in the UK that ensures patients with a suspected cancer are seen by a specialist within 2 weeks, even a presumptive diagnosis here can take many months. A recent female patient had a ‘mass’ removed from her womb 6 months ago and was told it was probably a cyst or fibroid (benign tumour). She has since attended twice with severe infections, anaemia requiring blood transfusions and a recurrence of her mass. She was referred to Kenema (the nearest government hospital) who subsequently sent her to Freetown. Even without a full set of investigations, her prognosis is questionable.  Without undermining the severity of her illness, sadly, in contrast to other patients who may find themselves in a similar position, she is comparatively fortunate in that her husband has the available finances to be able to take her to Freetown for treatment and pay for hospital bills. A significant proportion of patients I see appear to struggle finding enough money to meet their basic nutritional needs and the uncomfortable reality of having to alter prescribed drug treatment to fit with what money the patient has is a daily occurrence; investigation and treatment in Freetown remains a matter of fantasy for most.

In spite of this, the vocabulary and associated fear of cancer has, to some extent, penetrated even the most rural areas here. I saw a middle-aged (in UK terms, not Sierra Leonean) woman with a hard craggy mass in her breast that she had been observing grow over the last year at home in her village. When we discussed the possible causes of the lump, it was her who volunteered the word tumour and then broke down in tears after I agreed that this was a possibility. I saw her a few weeks later after she returned from Kenema saying that she didn’t have the money to pay for her scan or treatment.

Although, there are perhaps few similarities in the practice of oncology between the UK and Sierra Leone, one risk factor for the development of the disease which appears universally prevalent is alcohol. Not that I wish to do my dear friend Victor (the bar owner) a disservice, for better and for worse alcohol is rooted in daily life and with a 50ml sachet of 43% proof alcohol costing only 500 Leones (around 8 pence) alcoholism is regrettably within reach of even the poorest Sierra Leoneans.  

I hasten to add that our trips to Victor’s bar have become slightly less regular, but this in part due to the frequent evening downpours that dissuade us from venturing down the muddy road. Even if we do squeeze in a drink, we always appear to be trapped in a game of chicken with an impending mass of charcoal grey clouds that ominously approaches us over the ridge at the top of the village, often just as the lids are removed from bottles. The knowledge that you will have to race against the onslaught of a heavy thunderstorm does not make for a particularly relaxing drinking experience!  Although we should be heading towards the ‘dry’ season, the humidity doesn’t appear to be letting up. Even when the rain isn’t torrential there is often a fine mizzle that appears to descend from the skies to the level of your face but be absorbed into the hot dusty air before it has a chance to reach the ground. (How very British, a few months in and we’re back to talking about the weather…)

Incidentally, on the first day of reopening the library we only had one student come in to browse the available literary selection. As in all things, behaviour change takes time. When I was here in 2010 a significant proportion of free malaria nets that were distributed were used to catch fish as people thought this was a more productive use for them. Three years on, thankfully through education, more people use them to sleep under. Hopefully we will increase the library use with time by promoting the benefits of reading.  Thankfully tonight I have just returned from a heartening few hours with a library full of students.

 

Update on Evelyn: When I ventured down one evening to collect her empty pots I was saddened to see her bed empty and the pots stacked neatly on the neighbouring bed. Fortunately one of her fellow TB patients explained to me that she had got fed up of waiting for her TB drugs, supplies of which ran out 10 days ago and decided to venture back to her village to see her family. Frustratingly there is a national problem with the supply of TB drugs in Sierra Leone and daily calls to the district TB coordinator have thus far proved fruitless. Whilst I am thankful that Evelyn now has the strength to travel to see her children, partially treated TB will most probably recur and may be more difficult to manage due to problems with the increasing resistance to drugs.  We have sent word to her village and hope she will return to the hospital soon.

Update on Tomatoes: Doing well. Watering was a problem last week as we were both scared by a fist-sized hairy spider trapped with between the pots in the gap between the shutters and the window but thankfully the creature (George) has now departed. We are exploring the options for planting out but the choices for ‘grow bags’ are a bit limited!