Drums of Silence

Ben Cowan is a logistician working with MSF in Sierra Leone. His assistance of the surgical team meant he witnessed the realities of Sierra Leone’s high infant mortality rate.

Hours ago the doctor examined a pregnant woman; her condition was worsening and she still had not given birth. Difficult births are alarmingly common in Sierra Leone, and the MSF clinical team in Magburaka are wellknown for performing life-saving Caesarean section operations that are referred to the hospital; the MSF doctor and I leave to see whether this may be another case tonight. Luckily tonight I am only her chaperone for logistical support; this was not my time to save lives, but hers.

Our Land Cruiser’s reversing lights reflect dimly on the white walls to the maternity ward, then our driver pulls the handbrake and for a moment they glow red. The labour room emanates stifled screams of pain and frustration; the doctor steps out of the vehicle and quickly enters. When I arrive at the door the night nurse and doctor are reviewing patient’s notes under the harsh glare of a solar-powered strip light. Sadly the fetoscope has already declared the baby dead, but as yet even the latest series of contractions have been unable to deliver it and the medics now have to decide whether the baby needs to be removed on the operating table in case we lose another life tonight.

Outside the husband and relatives sit anxiously on a bench; their faces lit by a single hurricane lamp, the dim light unable to mask their worst fears.

One of the hospital guards arrives ready to switch on the generator; another porter wheels a stretcher trolley to a halt outside the door, and we all stand waiting for the decision. Without the normal assistance of hi-tech machines the doctor’s brow furrows for a moment, then with a turn of the head and bright eyes of conviction she says “This baby needs to come out. Come on let’s get her into the operating theatre.

The husband does not agree at first, he looks very afraid. Soon however, reassured by the doctor’s calm words, he consents that the treatment is best for his wife. Mustapha the guard steps out into the darkness behind the hospital to start the generator, other theatre staff are alerted by radio.

Moments later the generator whirrs into life behind us and suddenly power is delivered; volts flow along the cables like blood being pumped into the veins of the hospital. One by one the fluorescent strip lights flicker along the central corridor as far as the eye can see. Ceiling fans in the wards begin to beat their wings, causing cooler air to be blown down upon dampened sheets and fevered brows.

Alex, the porter stretchers the young woman along the corridor towards the Operating Theatre, passing patients’ relatives and more sick sleeping in the shadows on the concrete floor. There is stillness in the air and a smell that is hard to forget; it is the smell of sweet sickness; a smell produced in the continuing battle between disinfectants and infection. Soon the ceiling fans on the wards begin to waft the odour into the path of the trolley, and for a moment it causes the porter to gag.

The strike over pay continues and so there are few staff visible; most Ministry of Health staff are absent from the wards, redoubling the pressure on the remaining MSF medical staff present. We are told firmly that our work can only continue if patients require emergency treatment.

Intermittently the thermostat prompts the air conditioning unit to blast welcome cool air across the facemasks of those surrounding the bed. The patient’s pain is now anaesthetised and she is silent. Four pairs of eyes stare down at the swollen belly, now brushed brown/orange with Iodine in preparation for the first incision.

The surgeon’s scalpel is swift and precise; quickly and effortlessly exposing a yellowish fatty tissue beneath the skin. There is a pause before a vital movement of the blade causes the waters to burst. From this point the surgeon would normally have approximately four minutes to save the child’s life, but this time the mother is the primary concern.

Suddenly without warning, fountains of red liquid cover gowns and rubber boots and pour down the operating table stand to form puddles on the floor. The waters are coloured by blood bled from a ruptured placenta, confirmation if confirmation, is needed, that the decision to operate was an excellent one.

The dead baby is extracted from its mother and laid on a green drape over a stainless steel paediatric trolley. To me it is saddening to see all of the energy and attention focused away from the grey-coloured infant lying motionless and alone in the corner of the theatre while the mother is sutured.

Later in the night the atmosphere in the theatre is utterly different when a second pregnant woman requires help from the surgeon. After the C-section the baby is alive, although at 26 weeks, severely premature. The mood is lifted when the new born starts to breath by itself. Nevertheless, when the night’s ordeal is over, there is still much concern for the child. It will need to be fed through a tube 24-7 if it is to stand a chance of survival.

It is a harsh life to live in this country, especially for a woman. One may carry the burden of a child many times, but for no living infant to come forth. Mothers will have to eat for two when there is little food available; pressure from husbands grows to deliver progeny for them while he may have other wives to choose from. Others may suffer at the hands of the community and secret societies label them a witch when their third child dies.

It is a surprise to new expat midwives that arrive to see mothers showing little obvious affection or joy when a screaming healthy baby bounces into the world, however in time it becomes no wonder that they are not forthcoming with investing emotionally in their young infants straight away. Instead mothers appear saddened, not devastated, and relieved not elated, for there is much that is distressing and unfair.