Cradle to grave in Sierra Leone

This article first appeared in The Sunday Times magazine.

Tom Craig

"Heads would roll in England if a consultant saw a 17-year-old in this state. Her seizures have caused her to bite through her tongue, and it's so swollen that it's protruding from her mouth. The nurses have jammed a stick between her teeth but, coupled with the crucifix position, it looks like a grotesque form of torture."

It's 11pm and I'm in a Médecins Sans Frontières (MSF) operating theatre in Kambia, a remote town in northwest Sierra Leone. I'm using my weight to hold a pregnant 17-year-old girl to a table. She lies in the crucifix position with each hand anchored to a wooden board, but her unfettered legs keep jerking and sliding towards the floor.

A Dutch doctor and an Irish nurse are scrubbing up in another room, while two Sierra Leonean nurses hurriedly assemble the anaesthetic and equipment for an emergency caesarean section.

The closest I've been to childbirth was my own pleasantly painless labours, courtesy of epidurals, while my husband put on a brave face. I try to look intelligent when Dr Anne-Marie explains that the patient's suffering from eclampsia, but the only eclampsia I know is pre-eclampsia.

Heads would roll in England if a consultant saw a 17-year-old in this state. Her seizures have caused her to bite through her tongue, and it's so swollen that it's protruding from her mouth. The nurses have jammed a stick between her teeth but, coupled with the crucifix position, it looks like a grotesque form of torture.

Her name is Wara, and her husband brought her here half an hour ago. One of the nurses asked him why he waited so long but she knew the answer already. It took him 12 hours to borrow the money to make the six-mile drive from their village. Sierra Leone is the third poorest country in the world and, with no public transport, vehicle owners exploit the needy. The closer a patient is to death, the higher the price.

Tom Craig

Sierra Leone is the third poorest country in the world and, with no public transport, vehicle owners exploit the needy. The closer a patient is to death, the higher the price.

Wara will die unless her baby is removed. The good news is it's still alive: Anne-Marie has picked up a heartbeat. The bad news is she knows nothing about this patient except that it's a first pregnancy. Wara has never been to a clinic, nor had her blood pressure checked or treated, and her husband's unsure when the seizures started because, in this society, men do not attend births. He can only repeat what Wara's traditional birth attendant (TBA) told him, and that information is unreliable.

TBAs have worked in Sierra Leone for centuries. They have herbs that can stimulate contractions, but most use them indiscriminately. The results of misuse can be horrific (excessive bleeding, ruptured placentas, retained placentas, obstructed labour, untreated eclampsia) — which may explain why women in Sierra Leone have a 1-in-50 chance of dying every time they get pregnant,and why one in five babies is stillborn.

This operating theatre bears no resemblance to anything I've seen on Casualty. It's a room in a house, and the table is so narrow that Wara's body covers it entirely. I notice blocks of wood under the legs to raise it to working height, and I worry that each new convulsion will topple us over. Ancient wooden cupboards stocked with swabs and sutures stand in the corners, and dim light is provided by an outside generator. The smell from the latrines is so pervasive that I'm grateful for the surgical mask that filters some of the odour. I feel as if I'm in a Victorian novel.

Kambia hospital was destroyed during Sierra Leone's 11-year civil war. The war was declared over in 2002 after deployment of a large UN peacekeeping force and British troops — a military intervention that, for the moment, Tony Blair can count as a success. With no hospital, MSF rented the largest available house and turned it into a 68-bed inpatients' department by building an extension and erecting a tent in the garden.

There's no running water and intermittent electricity. Every bed is full and each patient has one or more caretakers to cook and clean for them. Some days there are upwards of 200 people in a house that was once used as a family home, and the heat can be unbearable. Even at 11pm my gown is sticking to my back, and I wonder how Dr Anne-Marie and Nurse Marion cope in the middle of the day, when the temperature outside exceeds 30C.

A new hospital, funded by the European Union, is under construction nearby, although Gerry, MSF's English project co-ordinator for Kambia, faces months of negotiation with the Ministry of Health to secure a dedicated maternity and paediatric unit. MSF focuses on mother/child health, with special emphasis on antenatal care and safe delivery.

In a country like Sierra Leone, with high mother/baby mortality rates, specialist maternity care is essential. I'm shocked at how devastating full-blown eclampsia is, and look up with relief when Anne-Marie and Marion return, fully gowned and gloved, to start the operation. I have no medical pretensions at all. I may write about murder but I'm not that keen on blood.

A cordon of sterility is established, anaesthetic is administered and everyone starts barking instructions at me as if I'm part of the team.

In a country like Sierra Leone, with high mother/baby mortality rates, specialist maternity care is essential. I'm shocked at how devastating full-blown eclampsia is, and look up with relief when Anne-Marie and Marion return, fully gowned and gloved, to start the operation. I have no medical pretensions at all. I may write about murder but I'm not that keen on blood.

There's nobody to direct the lamp light onto Wara's abdomen so that Anne-Marie can see where to make her incisions. I'm ordered to hold it steady. I manage fairly well, except for one small wobble when amniotic fluid suddenly sprays from Wara like a fountain. A few minutes later, Marion shouts for a fresh pack of swabs. I find them and succeed in opening the Cellophane wrapper without contaminating the sterile contents. Suddenly a tiny boy, weighing just over 3lb, emerges through the incision. He has virtually no colour, he isn't crying or breathing, but he does have a heartbeat. One of the Sierra Leonean nurses scoops him into a green sheet and, together, she and Anne-Marie attempt to revive him with oxygen.

We wait in silence until a thready cry and a sudden fluttering in his chest tell us he wants to live. It's an amazing moment which turns all too quickly to tragedy. Marion, removing the placenta, has discovered another foot. It's a little girl, half a pound lighter than her twin brother.

Anne-Marie tries to revive her but, with no heartbeat, she instructs all efforts to be concentrated on the viable baby. Later, I ask what would have happened if the second baby had responded.

"The same," she sighs. "With only one oxygen set, I have to choose the twin with the best chance of survival."

When I finally reach my bed an hour later, I fall asleep wondering if minor celebs who pay for "cosmetic" caesareans know how much cutting and tearing is needed to get inside a woman's uterus. If they do, they need their heads examining.

The life of a sick woman has less value than a man's, while the life of a sickly child has none.

It's seven hours later. I'm in a 4x4, travelling north to the village of Tombo Wallah with Isabel, a volunteer from Germany, and her Sierra Leonean colleague, Emmanuel. The 30-mile journey takes three hours: two hours on potholed dirt roads, then a further hour in a small wooden boat. Isabel and Emmanuel do these trips every day, and I admire their good humour and resilience. All MSF staff cite the difficulty of travel as one of the main causes of mother-and-infant mortality.

The roads are so bad that only lorries and 4x4s can negotiate them successfully. In places, we see some road-flattening and hole-filling, but new ruts open up as soon as the rains come. The only tarmacked roads are in the north of the country, and were given and constructed by Germany in the 1970s and by France in the early 1990s. I'm impressed by this sensible use of donor money in a country where corruption is rife. Finished roads don't disappear into government pockets.

Isabel and Emmanuel are MSF outreach nurses, and their patients are women like Wara. I hear numerous horror stories about what happens to women in the bush. Certainly Wara's experience suggests that if the drive to Kambia had been twice as long, she would never have reached the hospital. The life of a sick woman has less value than a man's, while the life of a sickly child has none.

The horror stories are too unpleasant to relate, but the difficulty of acquiring blood proves the point just as well. If a woman needs a transfusion, someone in her family has to be persuaded to give a unit. It's a frustrating business. Relatives vanish mysteriously as soon as the request is made, and doctors waste precious time negotiating for the single pint that can save a wife or a daughter's life. By contrast, if an old man needs a transfusion, male volunteers queue for the privilege of helping him.

MSF's plan to support a state-run blood bank at Magburaka, four hours east of Kambia, has already run into problems. People are willing to sell their blood but they won't give it free, any more than they'll give a free lift to a dying woman. Social responsibility is a western concept that carries little weight in a country of subsistence farming, poverty and malnutrition where memories of a brutal civil war are still fresh. People smile all the time here, but I've no idea if they trust each other.

Rumour has it that Sierra Leone's palm-fringed beaches were once chosen as the setting for the Bounty "taste of the tropics" ads. They're certainly beautiful, as is the rest of this verdant sub-Saharan country. It should be a land of plenty, but only a tiny percentage is cultivated.

Skinny sheep and goats roam the villages, but it's rare to see pigs or cows. Tilling and planting are done by hand and families grow only enough for themselves. Without roads and vehicles, their opportunity for trade is limited, and without money they can't buy seeds. In order to earn cash, they send their sons to the capital, Freetown, or to the diamond mines, and without sons to work the land, the land isn't worked.

It's a depressing cycle, reminiscent of England before the industrial revolution, and it can't be broken without huge investment in infrastructure. I ask our driver about Sierra Leone's diamond mines. Who owns them? Where does the money go? He hints at corruption in high places, and foreign businessmen with Swiss bank accounts. As this was the perception before the war, I wonder what all the death and destruction has achieved.

She doesn't know how old she is but the nurses put her down as 28 because her first child, a 10-year-old daughter, was abducted by rebels three years ago.

We approach Tombo Wallah by water, keeping a wary eye out for crocodiles. Wooden boats line its muddy beach, and tropical jungle sweeps the banks on either side. Single-storey houses with rusted corrugated-iron or thatched palm roofs border a yellow dirt road, and the vibrant mix of colours against a clear blue sky is breathtaking. We wade through shallow water and children run to greet us. As we walk to the clinic, they dance around us, clinging to our hands.

There's a queue of patients. The first is Amie Turay. She's 38 weeks pregnant and has been brought by her elderly husband after experiencing pains in her abdomen. They've walked an hour to be here. She's an epileptic with a withered left hand and some paralysis of her left leg. She doesn't know how old she is but the nurses put her down as 28 because her first child, a 10-year-old daughter, was abducted by rebels three years ago.

As first pregnancies usually happen at 15, simple mathematics gives an approximate age. She looks younger, while her husband looks a great deal older, but impressions can be deceptive in a country where the average life expectancy is 37. Amie is Mr Turay's second wife and this is her sixth pregnancy. She has two surviving children. Of the other three, the eldest was lost during the war, one was stillborn and another died at two months old, probably of malaria.

Sierra Leone has the highest infant mortality rate in the world, with one in three children dying before their fifth birthday. Malaria is the big killer. In sub-Saharan Africa, 2,800 toddlers die each day from the disease, and Sierra Leone, the worst-affected, is still using chloroquine, a first-generation remedy that no longer works.

Mr Turay agrees that Amie should return to Kambia with us, although he claims he won't be able to find a caretaker for her. Amie is worried about the journey. She's never been farther than Tombo Wallah, and doesn't know where Kambia is.

The next woman has oedema (bloated legs and abdomen) and she's advised to come to the hospital as soon as she can arrange caretakers for herself and her five children. Her name's Asatu and she tells Emmanuel that she doesn't like her husband, and she'll only come to Kambia if the doctor will sterilise her without asking his permission. She's 35, on her eighth pregnancy and doesn't want any more. Reassured, she agrees to come in on Saturday.

The law of averages suggests that there will be more living children if a wife gives birth every year, even though her own chances of survival diminish with each delivery.

In countries where the next generation is needed to support a family, it isn't easy to persuade men of the advantages of family planning. The law of averages suggests that there will be more living children if a wife gives birth every year, even though her own chances of survival diminish with each delivery. A man can marry again and father more babies to keep him in old age. A wife becomes redundant when childbearing is over.

Not unreasonably, women resort to subterfuge to protect themselves. They visit the clinics for secret three-month doses of injectable contraceptive, or ask to have their tubes clipped during a caesarean. They blame their sudden infertility on illness or, if they dare, their hernia-prone husbands. Large numbers of Sierra Leonean men suffer from inguinal hernias, a bulge of intestine protruding into the scrotum. MSF's policy is not to operate unless it is life-threatening.

I wander down to the riverside with a troop of children in tow, and find Mr and Mrs Turay waiting patiently in the shade of a tree. As I hand out baby wipes to the youngsters, the couple draw close out of curiosity. I offer a wipe to each of them. Amie takes hers to clean her hands, and Mr Turay tucks his surreptitiously into her bag so that she can use it later. I like him for that and hope it means he'll find a caretaker for her. When we finally board the boat, he stands in the shallows and waves goodbye until we're out of sight.

Amie looks so forlorn that I wish I could comfort her. When we climb into the 4x4 at the end of the boat trip, I ask Emmanuel to give her a sandwich, as I don't think she's eaten all day.

"She'll be sick," he says, matter-of-factly. "This is her first time in a car." But he gives her one anyway. I prepare to sacrifice my hat as a sick bag.

Nobody who travels in an MSF vehicle can be in any doubt of the charity's high standing. Everywhere we go, people wave and chant: "Em-ess-eff... em-ess-eff." I grow so accustomed to it that, as we approach a village, I assume the people running towards us are being friendly until the driver slows to speak to them. One of their women is having problems with labour.

Her name's Fatmata, she's 34, and this is her sixth pregnancy. Isabel and Emmanuel decide to take her on to the hospital.

The vehicle's already carrying eight passengers and there's a whirl of activity as bags and boxes are tied to the roof in order to accommodate Fatmata. Amie squeezes up the seat and valiantly refrains from being sick. By contrast, Fatmata cries and clenches her fists all the way to Kambia. Nobody says anything. We're too busy praying that twins don't appear in front of us.


I spent a week in Sierra Leone and witnessed too many harrowing stories, but I left with a sense of optimism because MSF's free health care is working. Mr Turay surprised everyone by coming to Kambia himself to act as Amie's caretaker, and with proper monitoring she gave birth to an 8lb baby girl. They plan to try again for a boy.

Tragically, Wara's little son died after three days because he couldn't suck. Wara recovered, but it was a long time before her tongue healed. Her husband still has to repay his loan, but he's thrilled that Wara's alive and able to have more babies. He refuses to leave anything to chance, however. In future, she'll be attending the antenatal clinic.