Saturday, March 7, 2009

Thoughts on Sierra Leone from George

As I begin, I feel I should be banished to blogger’s hell for my failure to post anything while in Sierra Leone. Thanks to Ray and Jim for posting what they did. For myself and Bob, we were saddled with a training schedule that went from dawn to beyond dusk, and by then the Bo Internet Cafe was closed -- which had the only point of Internet connectivity.

Apologies made, let me offer a few perspectives on our trip:

“Do little things with great kindness”

The days prior to a training trip are hectic. We had to finish the training manual, arrange for the final pickup of medications and equipment, and get everything packed into a 44 kg baggage allowance. So many people stepped forward with the little things that make this effort possible. Lisa McLean and the ob nurses at St. James Hospital in Butte arranged and paid for additional meds and donated retired nursing uniforms. Insty-Prints did a fine job printing the “Safe Passages” training manual. Assembling the rescue kits – bags and masks to resuscitate newborns, magnesium to prevent a newborn seizure, misprostol to stop a post-partum hemorrhage – I am struck that this work is not about big things, but little things. Little things done right save the lives of mothers and babies.

“On a jet plane”

We made the baggage allowance and started the journey – Butte to Salt Lake City, Salt Lake City to Chicago, Chicago to London, London to Freetown. What, no direct flights from Butte to Sierra Leone? On the last leg (London to Freetown) I met a young man traveling to be with his father, who had had a stroke in Sierra Leone six days earlier. The man hadn’t spoken to his father in two years. By chance I was sitting next to an Indian businessman who was well connected in Sierra Leone. When he saw the plight of the young man and his father, he went out of his way to help.


When you fly into Freetown, you actually land at Lungli International Airport. This presents a unique challenge. The airport is north of the Sierra Leone River where it flows into the Atlantic Ocean. Freetown, the capital of Sierra Leone and its largest city, is south of the river estuary on a peninsula. The Indian businessman arranged for us to take a helicopter from the airport over the water to Freetown, and then his driver took us to the hospital. Most travelers take a water taxi, ferry or hydroplane to get to Freetown, which has the third largest natural harbor in the world and is the starting point for most in-country travel. Our Family Health Alive-Safe Passages training to prevent maternal and newborn deaths was to take place in Bo, well inland. (See Blog map of Sierra Leone.)

We arrived at the hospital near midnight. The father was paralyzed on the right side and could barely speak. When he saw his son, tears streamed from his eyes. I examined the patient and called his local doctor. They had no CT scan and had been treating him with steroids and mannitol – but apart from that had done a good job. We made plans to take his father out with us the following week. Good people – the son in search of his father, the Indian businessman, the nurses trying to comfort a patient in a completely different world.

“To be DRY”

Imagine being a young woman with urine dribbling out of your vagina everyday. You smell, you are dirty and poor, and you are rejected by family and village. Somehow, you found your way to the West African Fistula Foundation and a surgeon named Darius Maggi. He and his team welcome you, comfort you, feed you and prepare you for surgery. A few weeks later your fistula is repaired. After the foley catheter is removed, you no longer leak urine. One word, one beautiful word – DRY. You are dry. To be dry is to be alive; to be dry is to become human again.


As we entered the fistula ward, the women burst into song at the sight of Dr. Maggi. This man and those working with him had given them a new life.

“Work begins”

Bob and I have done this many times. The opening day of the training workshop. How many people will come? What will be their skill set? Will we have electricity for the power point? Our mission is simple – provide training, inspiration and equipment to begin the process of change so that women don’t die in childbirth or develop complications like obstetrical fistula.
The lecture hall is full. Eighty people come from all over the country. There are physicians, midwives, nurses and community medical officers. They are eager to learn and participate. We are blessed to have dynamic leaders: Mrs. Betty Sam, the director of the Christian Health Association of Sierra Leone; Mr. Samuel Pieh, a native Sierra Leonan now working as a consultant for health and development in Liberia. They speak of a new day for women and babies in Sierra Leone.


Will the words become flesh? Will the protocols in the manual – the signs of preeclampsia, the dose of antibiotics, the order of resuscitation – move from word and print into practice? We shall see.


I begin with our core principles at Maternal Life International (MLI) – respect for the life and dignity of all persons, born and unborn. We exchange stories and questions. Bob takes them through the basics of antenatal care. He is the consummate professor, asking questions, drawing out information, helping explain not just the “how” but the “why.” They are 100 percent engaged – this is why they came.

The day passes quickly. At the end of each day, we always ask, “What were three things that were good about today?” and “What are three things that need to be improved?” They were superlatives for the training. What should be improved – they begged for a meal to be provided at lunch and they asked that we make time for prayer.

“Beneath a tree”

We start at 9 a.m. sharp with an hour to get things set up. We move to normal labor and complications of pregnancy and delivery. By the afternoon we are beginning small groups. I am rotating participants through basic neonatal resuscitation. There are no rooms apart from the main lecture hall, so we are under a tree outside. Ten, twenty, fifty times, each participant goes through the basic steps – position airway, suck the mouth then the nose, assess if on the “no breathing road” or “yes breathing road,” begin bag and mask ventilations, insure a good seal, “1 breathe . . . 2 breathe . . . 3 breathe.” Very few of them have ever seen a bag and mask for newborn resuscitation. Some have tried mouth to face resuscitation. The studies tell us that 23 percent of newborn deaths are from asphyxia. It doesn’t have to be that way.


In the afternoon heat, I am reminded of “the tree of life,” of God who “breathed life into man.” Oh to simply breathe, to fill an infant’s lung sacs with air and push out the fluid . . . forget for a moment about medications or surgeries, in those moments after birth, work for sweet and steady breathing.

“Stabilize and Deliver”

Nobody does a better job in explaining preeclampsia that Professor Scanlon. He takes the participants through the basic pathophysiology and how vasospasm affects every organ system. You can see the lights go on (even as the power and fans go off.) If they diagnose severe preeclampsia, management becomes simple – stabilize and deliver. And, thanks to our donors we have the “goods” to stabilize: magnesium for prevention of seizures, hydralizine to lower severe high blood pressure.


This isn’t Bob’s first rodeo. He takes it to the realities of providing care in an understaffed, poorly resourced West African Hospital. What if you don’t have urine dipsticks to measure protein? (Many health care providers don’t). What if you have no idea about the woman’s due date? (Many patients arrive “unbooked” without any antenatal care). What if the woman’s cervix is unfavorable and you have no one able to do a Cesarean-section? (Many institutions don’t.)


Bob finishes and one of the participants says, “This is fantastic!” They have seen too many women die from complications of preeclampsia. All of a sudden, they are educated and empowered to manage for this condition in a clinically sound and practical way. I get the sense of the “word is becoming flesh.”

WILL CONTINUE AND FINISH TOMORROW. FOR NOW, MANY THANKS TO ALL WHO MAKE OUR WORK POSSIBLE!

(To finish reading Dr. George Mulcaire-Jones reflections on Sierra Leone, please see blog posting 3/8/09)


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