Update: Sierra Leone 2
I cried. I actually cried. I got choked up - initially thought I could control myself - and then tears began welling up. I
looked away; I stammered. Before I knew or could control it, my cheeks were wet and streaked. I really cried.
Last Thursday was our final day at Connaught Hospital. For almost six weeks, we were part of the hospital family -
literally. We lived in the hospital compound, ate at the hospital canteen, rounded on patients in the hospital wards
and operated on patients in the hospital operating theatres. Constantly we were greeted with; “Ow da dai?”, “Ow
u slep?” or “Owz da bodi?” (How’s the day? How did you sleep? or How are you?). I would respond with “Plenti
fine”, “Nah bahd”, or “Beaucoup fine,” and then add a hearty, “An u suf?” (and yourself?). I always loved
tossing in a cheerful “Tel gowd thenki” (Tell god thank you) as inevitably everyone broke into loud peals of
laughter. We learned smoll smoll (a little) Krio, and we did smoll smoll operations, but I think we had a very big
impact.
The other day I jokingly asked some operating room staff if they were having a party for us on the day before we
left, or on the day after. My question was along the lines of the needlepoint in the guestroom in my mother’s
house that states, “Visits always give pleasure, if not in the coming, then in the going.” I hadn’t been
fishing for a going-away party and was actually embarrassed when I heard that one was organized. However, late
Thursday afternoon, after yet another meeting at the Ministry of Health and before giving a talk on burn
management at the Sierra Leone Medical and Dental Association, Reinou, TB, and I snaked our way through the
congested streets of Freetown. We drove past begging children seated in bright red wheelchairs, adolescent girls
balancing heaping platters of groundnuts (peanuts) on their heads, and countless throngs walking, working, and
living on the narrow, crowded and noisy city streets. Freetown has some of the worst traffic patterns I have ever
experienced. Gridlock is not just frequent; it is endemic. Trucks and taxis frequently breakdown, clogging the thin
ribbons of road; vendors scamper between vehicles hawking pirated videos, towels or candy bars. With some
difficulty, but in good spirits, we arrived back at the hospital.
To our surprise, the operating theatre staff had gathered in the conference room in front of a long white lace
covered table. Lilac colored plastic flowers adorned one corner. Reinou, TB, Dr. S.S. Dumbuya (head of the
surgery for the college of medicine) and I were given seats at the front. The rest of the staff gathered around the
room, the same room where we had been introduced when TB reinstated Friday morning morbidity and mortality
conference, the same room in which the details of the salary top-up was announced. (SIHS had initially planned to
provide salary support to the local surgeons; however, it was the surgeons who suggested that the funds be
spread among the entire operating theatre staff and with some additional monies distributed among the staff of
the surgical wards and the emergency room. The result is that a nurse who makes the equivalent of US$ 66 per
month will now receive an additional US$ 18. By US standards, it is not a great deal of money, but the effect on
the staff was immediately visible.)
People are continuing to talk about the workforce deficiencies in Africa and ways to prevent brain drain. Well, to
us it is simple. Pay people more; treat them with respect; and provide them with a comfortable, safe work
environment. We are doing that. In addition to the salary support, we are purchasing protective items: boots,
aprons, gloves, eye protection for the staff. These items will be part of a program we call S.H.A.R.P. (Surgery and
HIV/AIDS Response Program).
So on Thursday afternoon there was a party. Well, I guess I just expected a few of the staff to gather and say
thank you. However, all of the theatre staff were present. One of the nursing sisters began by thanking us and
sharing her personal feelings; she also specifically thanked the Society of International Humanitarian Surgeons. I
guess it was at that point I broke down. I was overwhelmed by the outpouring of gratitude, but also by the
realization that we had created an organization that was different and effective and useful. This wasn’t about the
work that I had done or the efforts Reinou and I had undertaken, but was about helping people help themselves.
We were the catalysts, we brought people and ideas together, let them work and then we left unchanged – but we
were certainly not unchanged.
Once again, as much as I give and do, I always seem to come out ahead. Sure maybe I don’t see all the risks and
problems, maybe it’s because I try to concentrate on the positives and discount the negative aspects, the
frustrations of working in Africa or realizing a different standard of care, of making compromises.
Looking back at the last six weeks, I can see many accomplishments. The easiest to document, but maybe the
least crucial, was the clinical work. I only performed six operations: four hernia repairs, one colon tumor resection
and one appendectomy for perforated appendicitis. Reinou did a bit more – assisting on almost 30 cases and
frequently making ward rounds with Dr. John, the local house officer. We also took emergency call for all of our
last week. We provided a little break for the local surgeons, and saw all emergency patients that presented to the
casualty.
More important than our clinical work, however, were the emergency and essential surgical care (E2SC)
workshops. Overall, they were a resounding success. We had some international participation, but more
importantly, we had a robust local faculty. Ten local specialists gave presentations and helped with practical skills
teaching. Forty-four students participated in the workshops (21 in Freetown, 23 in Bo). We had didactic lectures
and practical skills sessions including obtaining an airway, bowel anastamosis (sewing intestine together), chest
tube insertion, ear irrigation, and tendon repair. The sessions were made life-like by performing the procedures
on a butchered pig. Luckily, we were able to get the needed supplies to do all the suturing.
There have been surgical skills workshops in Sierra Leone before, but ours was unique. This was the first where a
majority of the work was facilitated by local surgeons. Sure, we provided the funding and assisted with some of the
logistics, but TB Kamara did the majority of the organizing – including inviting all the students, arranging the
venues, catering and faculty. The local faculty attended a facilitators meeting (hosted by WHO) before the
workshop, received copies of the Surgical Care at the District Hospital manual and Integrated Management of
Emergency and Essential Surgical Care tool kit, developed presentations, presented with a high degree of
sophistication, took time away from their own private practices and traveled with us to Bo.
Bo is the second largest town in Sierra Leone, but that isn’t really saying too much. It’s a rather sleepy place,
although the downtown market gets rather active. The workshop has held at the Njala University Paramedical
School and initially we planned to sleep there as well. We decided en-route to stay at the Hotel Sir Milton (named
after Sierra Leone’s first Prime Minister – Sir Milton Margai). As the best hotel in downtown Bo, it is rather
underwhelming. Rooms have mosquito nets, private bathrooms and running water, but a mustiness pervades
everything and with our room directly across from the entrance to the Black and White Restaurant/Club, rather
noisy. Luckily, we were a good distance from the Boom Boom Club - I shiver to think what that would have been
like.
So what is next after the workshops? Well, all the participants indicated that they thought the three-day courses
were too short. That is something we cannot change now given our limited resources, however, we are looking to
expand the program. I’ve drafted a short proposal and we will see about funding additional two-day workshops to
be held in the district hospitals. The plan will be for each of the 12 districts to host a two-day workshop where local
personnel, and doctors and nurses from surrounding districts can attend. We plan to divide the country into three
zones of four districts and then cover all the districts over a 2-year period. Teams of a local surgeon, OB/GYN,
and anesthesia specialist will travel to the sites and teach the sessions.
Additionally, we plan to have an evaluation of the workshops next month when Peter Kingham returns. As all
participants were initially contacted by mobile phone, we plan to call each participant and determine if and what he
or she were taught was of value. This information will be essential in planning additional workshops and proving
(hopefully) that the time and effort (and money) spent was indeed useful.
I blame the biggest disappointment of the mission squarely on the French. This summer a strike by French port
workers disrupted much of global shipping. With scheduled container vessels already making limited stops in
West Africa, our 40’ container of surgical supplies and equipment originally scheduled to arrive in mid-July had
not yet arrived when we left Freetown. In an effort to make lemonade from lemons, I’m looking and hoping that the
folks at the Ministry of Health follow through on their promises and see that there is a quick and smooth transition
of the container through customs and to the hospital. Once the supplies arrive at Connaught, then we will be able
to send additional teams of surgeons to operate on patients in need of surgery. If the container is delayed by the
National Revenue Authority, no teams will be recruited and future containers will be doubtful.
Anyway, Reinou and I are now back in the Netherlands, the town of Amersfoort to be exact. We will use this as a
base for the next bit. I will be heading to Geneva on Sunday to do some work at WHO headquarters for a week –
we have collected data using the WHO situational analysis tool for over 120 hospitals from countries including
Sierra Leone, Tanzania, Gambia, Sri Lanka, Afghanistan and Mongolia. Reinou will join me mid-week. On another
pleasant note, Dr. TB Kamara was invited to a WHO meeting on essential medical equipment and so we will get to
see him in Geneva as well.
After that, I have a number of training exercises that I’ll be participating in to help teach about NGOs and
humanitarian assistance, and I might be in Liberia for 10 days to do the situational analysis for all the government
hospitals in the country. The Ministry of Health in Liberia is keen on enhancing emergency and essential surgical
care. If I go, I will try to get an update out. Otherwise, the next one will probably be in November when I’m planning
to be back in India. I will cover for a local surgeon in the northwestern town of Manali, high in the mountains, and
that should be quite interesting.
At some point, I will be back in New York and I have also been invited to speak at this year’s American College of
Surgeons meeting in San Francisco on October 14th, so I look forward to meeting up with many of you surgical
types. So busy busy fall, but lots of good work and fun. Oh, and for the record, sure, I’m a little embarrassed
about crying in public, but sometimes things just can’t be helped.
Best to all,
Adam
PS: I also want to let you all know that my friend Alison Josephs did a great job of redesigning the SIHS/SOS
website. Feel free to check it out at www.humanitariansurgery.org.