Update: Sierra Leone 1
It was the best of times; it was the worst of times. OK, sure, that line has been used before, but for this
update, it seemed appropriate. For three weeks now (yes, with a five day hiatus where I flew 3,500 miles to
the Bellagio Essential Surgery Group meeting in Kampala, Uganda), I've been in Freetown, Sierra Leone -
and indeed, the same country of Blood Diamond notoriety.
Some may recall that in 2005, I spent three months working here at an Italian NGO hospital; some might also
recall there were "issues." Often I had thought "How can I possibly help to make things (and by that I mean
surgically) better in Sierra Leone?" Last Spring, when a few like-minded surgeons formed the NY Society of
International Humanitarian Surgeons, there was a way. (As an aside, due to immense global interest and
rapid growth, the NY was recently dropped and the organization will now be known as the Society of
International Humanitarian Surgeons (SIHS) - with a program arm: Surgeons OverSeas (SOS).
I am now back in Freetown, and with my partner, Reinou Groen, a Dutch tropical doctor, and the assistance
of many others, we are beginning the arduous task of improving surgical care in Sierra Leone - incredibly, we
are already making a difference.
Sierra Leone was ravaged by a brutal civil war that officially ended in 2002. Now, although endowed with
fertile land, mineral resources and access to the North Atlantic Ocean, the country has failed to rebound
economically. Additionally, health standards remain close to the worst in the world. Most striking is the figure
that for every 1,000 children born, almost 165 die before their 5th birthday. Maternal mortality is a major
issue, HIV is at 5-7%, and no one knows the numbers of people dying from surgically treatable and
preventable conditions. I do know however, that when one walks the wards of Connaught Hospital, the
recently renovated 85 year old 350-bed referral center for the country, one sees numerous patients with the
diagnosis of R.T.A. (road traffic accident), each with various body parts (depending on the injury) wrapped in
white gauze.
How many people die from a lack of surgery in Sierra Leone? We have no idea. One thing is certain, with a
population of 5 million, and a rough estimate of 2-3 thousand operations performed annually that number
seems grossly insufficient - a similarly sized population in the U.S. would undergo 500 thousand operations a
year.
So, what are we doing about the problem? The answer is quite a bit. At the moment, Reinou and I have been
helping out at Connaught Hospital, we have a 40' container of supplies and equipment en-route from New
York to Freetown, we have organized and are in the process of conducting emergency and essential surgical
care workshops, will be supplementing local hospital employee salaries, and are looking to assist with other
visiting surgeons.
How did this all develop? Back in February, SIHS director Peter Kingham visited Sierra Leone. During that
time, he met Dr. TB Kamara. TB is Head of Surgery at Connaught Hospital, an urologist by training, and a
lovely man. I had had the good fortune of meeting him a few times previously when he too was a volunteer
surgeon in Malawi. Peter and TB immediately hit it off, and a plan formulated to undertake a needs
assessment of the surgical capacity of Sierra Leone. Now one of the hallmarks of SIHS is that we do not do
things unilaterally. This assessment used a questionnaire developed by the World Health Organization, and
the Ministry of Health was involved and supported the entire project. Peter and TB spent 3 days transversing
the country and visiting government hospitals where surgery is performed. Incredibly, for 5 million people
there are only 14 government facilities, plus a smattering of private and mission hospitals.
The most glaring deficiency they identified was the complete lack of anything. What I mean is that hospital
structures are in place, but often they are completely void of equipment and supplies: items such as sutures
and gauze and gloves are totally lacking and must be purchased by the patient from pharmacies or on the
black-market. I am used to families having to provide meals and care for the patients, but to provide gauze
and i.v. tubing---?
As an aside, the first major success of SOS was the provision of light for the operating theatres in Connaught
Hospital. Almost incredibly, things are so bad that, like the story of the kingdom lost for want of a nail, surgery
at Connaught almost ceased for want of a US$ 0.30 light bulb. During the hospital assessment, Peter and TB
discovered that all the overhead operating theatre lights used the same type of light bulb; almost all the light
bulbs were blown, the equipment non-functioning, and no local source for the bulbs. Peter took a sample
back to New York and his stepfather sourced the bulbs from a factory in China. We now have 500 light bulbs
en-route to Freetown in as part of the container (including gauze, suture, medical books, stretchers, IV poles,
an operation room table and other equipment and supplies). An amazing side development was that in late
June, Peter and I received an urgent appeal from TB because the last light bulbs had blown in the theatre in
Connaught and there was no surgery being performed. Luckily, SIHS member, Thomas McIntyre (Kings
County Hospital, NY) was about to leave for a short-term mission in Sierra Leone. Peter hurriedly took a taxi
and dropped off the five sample light bulbs he had (the container was already packed and en-route).
Thomas arrived to literally save the day for multiple patients in need of surgical care. In fact, the case I did
Monday would not have been possible without all the effort of those involved.
So, here's the deal. On 15 July, Reinou and I arrived in Sierra Leone. The airport is located across the mouth
of a large expanse of water and we needed to take a hovercraft to town. There is also helicopter service, but
with two crashes earlier this year, most people avoid the flight if possible. The next morning TB showed us
our new home - a two-bedroom apartment in the Duty House at Connaught. The place had been readied for
us, was in immaculate condition, complete with refrigerator, fan, mosquito nets and toilet, the only slight
nuisance was the lack of running water, but barrels of water were provided and bucket showers are really not
too bad. Besides, as there is no running water for the entire hospital, for that matter almost every hospital in
Sierra Leone, how could we complain?
Slowly we have been integrated into the workings of the hospital. Our major disappointment with the mission
is that with six consultant surgeons and numerous support staff, with the current patient load, there is no real
need for additional personnel. Although there are six operating rooms, only one is fully functional. Most days
there are three or four operations, although one day they did seven, which for the conditions is impressive.
While many of the cases are appendectomies and hernia repairs, there have been a number of orthopaedic
cases, a hysterectomy, a nephrectomy, and a urethreoplasty. In addition, emergencies are seen and
operated on, although not at the numbers which one would expect, or in enough volume to keep Reinou and
me very busy clinically. Reinou has assisted on about two dozen operations. I've only scrubbed once (for a
patient with a large colonic tumor). Of course, the lack of running water in the operating theatre means that
one scrubs from water poured out of buckets held by the nurses.
Incredibly, we have increased the number of capable surgeons in the country by almost 20%, yet, the
number of cases have not caught up with that. The problem is (I'm told) the lack of supplies. Most people can
not afford the materials needed for the operations, or the hospital fees, they then will sometimes go to the
free mission hospitals. Things are so bad, that the system is not able to adjust to the additional support. At
the moment.
Our plan, and commitment, is to assist the Sierra Leoneans in improving the surgical capacity for the country.
We are doing that through a number of initiatives. The first is the 40' container; secondly, we are organizing
emergency and essential surgical care training workshops. The two workshops are taking place this week,
one here in Freetown, and the second, upcountry in the second largest city, Bo. The workshops are 3 days
long and cover material found in the World Health Organization's manual, Surgical Care at the District
Hospital. WHO has donated 55 manuals and CD sets and we organized a local and international faculty to
teach the material. Ethicon (Johnson & Johnson) is also providing partial funding. Drs. Steve Mannion
(orthopaedic surgeron) and Jim Ryan (war/trauma surgeon) are two UK based surgeons who are assisting.
Reinou will cover the emergency obstetrics topics, seven locals will be covering topics such as orthopaedics,
anesthesia, urology and ENT and I'll be around to assist with the organizing. We are very excited as almost
all the trained surgeons in the country will be acting as lecturers, and the students, approximately 40,
represent almost every person performing surgery. It is, however, a sad state that with this relatively small
initiative we can cover such a high percentage of the surgical providers in a country.
On another positive note, I've met a few times with the Minister of Health, Dr. Soccoh Alex Kabia and he is
exceedingly interested in helping to improve surgical care. He has asked us to sit down with him and his staff
to create a national plan for improving surgical care in the long-term. Again, this is how we feel that SOS
programs should be organized. Our goal is to save lives by working with locals - although it's a term that I
think is overused, we are really 'building capacity' here. This is not a specialty group going for one week to
operate on a hundred children with a specific deformity. What we are talking about is being able to save lives
and limit disabilities for all the people in the country from conditions that we take for granted back home:
appendectomies, caesarean sections, hernia repairs, casting of fractures. In Sierra Leone, odds are if you
need one of these procedures you will either die or be left crippled. In our minds, that is unacceptable.
Therefore, on the positive side we are looking to assist an entire country in developing an exciting new
approach to a problem that routinely has been neglected by the public health community. During the conflict,
there were programs to assist civilians and there are still some mission hospitals, however, we are looking at
an entirely new approach, one that includes the government, academics, charity organizations and we hope
businesses. I just want to say thank you to everyone who helped to make this mission a success, and I'll let
you all know how the workshops go.
All the best,
Adam