If you can walk, dance...

"Spring greetings from the MSF Project Coordinator in Kambia Town, Sierra Leone, (turn left at Piccadilly Circus and then its sort of straight down all the way…)!

Most of the compound is lit with lanterns. I’m seated at a rickety old desk with my laptop in the early evening in what used to be a tool or donkey shed - hard to tell! -, now an MSF logistics/communications centre, made of brick and mud. The shed is at the far end of a large compound, around the size of half a football field. Surrounded by a fence made of thick wood stalks and palm leaves, the compound is carpeted with sand and is home to a rich tapestry of palms, plants of all ilk and to our house, bedroom tukuls and the crowning glory, a large tukul, a round seating space with a wood and straw roof, where everything and anything to do with work, play and drinking happens. All five of us live and work together 24/7 and so you can imagine that after I while we get to know each other pretty well, even if only our habits! Life here is unavoidably intimate and intense and constantly so. We are pretty familiar with each other’s underwear and not for the reasons that you are thinking.

The compound itself is in the heart of old Kambia town, which has around 7,000 souls living in its streets, hill and forest areas. It is one of Sierra Leone’s – and therefore the World’s – poorest places and life here is simple and basic, with its average life expectancy of a staggering 37 years of age. Sierra Leone, the size of the Irish Republic, has officially the worst health indicators/health ranking on the UN World Development Index in the world. As a result, you can see people vanishing from this life as a result of the most simple of medical complications: to take one example, and the one in which we are most involved in our hospital work, there are an incredible 170 deaths per 1,000 live births (i.e. almost every fifth baby dies during labour or just after birth), an under-five mortality rate of 286 per 1,000 (in other words more than one quarter of all children who survive the first hours of life die before they reach the age of five) and an unbelievably high maternal mortality rate of 1,800 deaths per 100,000 live births…. And the number one killer of under 5s is malaria, in large part caused by the long delay in getting the Ministry of Health to accept that chloroquine, the current first line treatment, has a resistance rate of 80% in these lands… After years of building up pressure, MSF has just had a breakthrough concerning the introduction of a new treatment, ACT (click here for more details about ACT) which we hope will save tens of thousands of lives as soon as it is introduced.

Recently one of my colleagues, Samuel, came into my office with a small photo album. He looked at me with large sad eyes and asked me whether I wanted to see photos of his daughter. He then sat me down and showed me about 50 photos of the funeral 6 months ago of his beautiful 8-year old daughter who died from cerebral malaria. Even when Samuel is smiling (and he never laughs much), you can still see the sadness in his eyes, you can see how she is never far from his thoughts and that he misses her. And then, in the middle of showing me the pictures, a very Sierra Leoneon thing happened. He asked us to say a prayer together for his daughter. The people of Salone like saying prayers in public … every public meeting starts with a public or silent Christian and Muslim prayer. So there we stood, praying, whilst the government was still pushing chloroquine……

Our northern European team here in Kambia, one of three MSF project teams in Sierra Leone, is made up of one Dutch Doctor, an Irish nurse (for the hospital), a German Nurse (for the clinics), one German logistician and a British PC and our work is split into two main projects. The first is provision of secondary health care in the local hospital, which consists of a house rented by MSF since 2001. The old District hospital was bombed to pieces in 1999 by the Guinean military who were trying to get rid of RUF rebels who had taken over Kambia at the time. With the help of the EU, the new hospital should be finished in a few months time and we will move into it as soon as possible. In the meantime, we remain in our makeshift hospital with two of our medical expats working as the senior medical staff in conjunction with the Ministry of Health’s nurses. Most of the doctor's surgical work involves emergency surgery on pregnant women (“emergency obstetrics”) although she also does other forms of elective surgery. Our nurse has daily responsibilities for the smooth functioning of the wards and works closely with the matron, the wonderful and charming Sister Batty.

In amongst the sadder daily stories in our little hospital, we had one with a happy ending recently. A woman with twins and in obstructed labour arrived with her elderly mother. Without a hospital, that woman would have been guaranteed an early death as sure as not going to hospital after a serious car accident would guarantee the same. She was one of the lucky ones who made it to Kambia town…. Equipped with cameras I watched 40 minutes of attempts to get her to push hard enough to try and force a normal delivery and with such difficulties the lapse of time was dangerous for the mother. It was finally decided that we had to do a Caesarean section and half an hour later, after our doctor had weaved her wonderful skill with calm professionalism, I was cradling the first of two 3 kilogram twins. The grandmother saw me walk out with both boys in my arms (it’s clearly in my job description to carry the babies from the Operation Theatre to the labour room!) and started dancing like you have never seen a 60 year-old dance before. As they say in these parts, “”if you can walk, dance”. It was a very joyful sight to behold.

The other area of our work is in far-flung rural communities to the south and west of Kambia. Our clinic nurse visits six clinics where she trains staff, deals with patients and from where we have recently launched an “outreach programme” whereby we train and then send outreach workers into remote rural areas to make villagers aware of the existence of the clinics and of the fact that the clinics can refer people to our hospital here in Kambia if needed. Above all, we focus on pregnant women and under 5s, for the reasons mentioned above.

The village of Tombo Wallah is the remotest of our 6 clinics and a definition of remoteness and health care neglect. Surrounded by screaming and beaming little children we make our way to the clinic where our nurse trains some of the local Ministry of Health staff to deal with complications directly in the clinics and from where we refer (and sometimes transport) urgent patients all the way back to our hospital in Kambia: without that referral possibility, there would be no hospital for these people to go to and a major part of our advocacy at Freetown level is to remedy this appalling lack of access to basic secondary health care.

As we wove our way back, I tried to make a mental note of some of the finer inscriptions adorning the front of the local buses: “Try Islam”, “God is One”, “Beware of pickpockets”, “God bless Islam”, most worryingly “I trust in God” and my favourite: “Don’t give up”. Sierra Leone has a scary number of road deaths a day, mostly caused by bus drivers trusting in the saviour and bus manufacturers doing the same when they construct the bus in the first place. Still, unlike in western countries where road accidents figure very high up on the list of greatest cause of premature death, here pre and post natal maternal deaths, malaria, TB and a host of other easily preventable causes figure far higher up the list and so road accidents are relegated to inevitable acts of God even more than they would be if they were the number one or two killer.

The number of health meetings that have recently been called to address these killers has recently increased and again at these meetings, the importance given to protocol is there for all to see. A recent tuberculosis (TB) sensitisation meeting here in Kambia town saw a lot of local and national dignitaries gather together in the town gathering area, an open concrete structure with no doors or windows, teeming with children on benches sucking on oranges and falling about laughing at the introductory, highly dramatic and noisy TB play being preformed on stage by zealous health educators.

“We are waiting for the chief” said the lovely District Health Sister, Sister Fuller from the District Health Management Team, when I enquired some 10 minutes after the last actor had been carried off stage - heavily bleeding on a stretcher - why it was that we were all waiting, given that the dignitaries were all sitting at the table on the stage… “The chief…” she said, nodding knowingly. “He’s not here yet”. “Where does he live?” “Over there” she said, pointing at the nearest house on the other side of the dirt track… Not exactly what you would call a commute. We waited and the suspense was agonising but, as Sister Fuller herself said, it was part of the dramatics involved in protocol in this part of the world. The town’s Chief finally walked regally across the street clad in a large golden and white robe and cap, carrying a fine walking stick and with an entourage of 7 or 8 in tow…(including three of his 8 wives? Only 8???? Call yourself a man?????) and made his way to the grand chair that was brought on by 3 grown huffing and puffing men and parked in the middle of the table on stage. Not a word was uttered until he had sat down and surveyed the gathering with a kind smile and endearing gaze. A cameraman appeared out of nowhere and with a very subservient manner started capturing the assembled group on the stage. Two prayers were said out loud with an interpreter interpreting from Krio into Temne and Temne into Krio (when the Muslim prayer was said). The introductions took 20 minutes with every speaker introducing him- (or in one lonely case her)-self and the crowd sat in disciplined and attentive silence. In effect very little was said, but the atmosphere was very focused with the importance of the protocol impressing those assembled and possibly reinforcing the importance of the impending topic to be discussed.

As I sat listening to the Krio speakers explain to the assembled community workers about the lives they could save by making sure that people with TB symptoms are referred to clinics and possibly in turn to the hospital (“…..make aaaaaall man know dat dry coff be veeeeery baaaaaaad…..”), a little girl sitting on my right – wearing a striking white Muslim head scarf even further emphasising her big white eyes and teeth – touched my arm with a very concerned look on her face. She pulled a little at the skin and then did the same with my hand. Seeing my slight confusion, her brother also touched my arm and said “white white".

As the health topics came to an end, the Chief was invited to address the crowd about ….. Well, nobody was quite sure but after he had finished, 20 minutes later, he had added his moral emphasis to what the medical professionals and the elected politicians had said: “When u die, God saaaaay, why you not take medicine –and God nooooooot be haaaappy…” The two political systems in Salone, side by side, politicians and Chiefs sharing the stage, and the two great systems - medicine and religion - battling over fate, hand in hand, refusing to openly contemplate that religious and animist beliefs are in any way responsible for the terrible health indicators in this country (which they clearly are) and yet at the same time accepting that western medicine has its role to play and, even more, sorry eeeeevvaaaan moooaaarr, that God looks favourably upon such medicine. Coming from the Chief, this was an important message and one he asked the workers, in the absence of radio, newspapers, televisions and telephones, to take back to their villages to spread the word. I sat there thinking how it health education happened automatically in our countries, with parents being informed by health clinics with pamphlets, on TV with information, through telephone chats with fellow parents… None of those luxuries are, of course, available here to patients or to vulnerable little children.

Religion here is another fascinating issue. As I was recently driving back to Kambia as the night crashed down on the dusk’s last embers (who turns off the light in this place?? And why is (s)he in such a rush when everything else takes so bloody long???), it seemed that in these remoter areas, each set of houses maybe has a candle between them. I sniffed the fresh evening air and saw a group of villagers huddled together in the dark under a tree, kneeling, facing east. (Well, alright, alright, if I hadn’t known what they were doing I wouldn’t have had the faintest idea in which direction they were facing…!) As we slowed down we could hear a gentle chant and murmur. Menge, our wonderful all round compound manager, explained to me how Christians and Muslims live side by side and inter-marry in complete harmony. He himself is Muslim, his wife Christian and their children go to Catholic school where part of the teachings focus on the Koran. A young man by the river with whom I was chatting the other evening after a swim told me that although he was Muslim, the reason he was wearing a glistening silver crucifix around his neck was because it was “so beautiful”. Can we please arrange for Messers Bush and Bin Laden to spend a dirty weekend together in Kambia? I know a lovely little hotel….

On what really matters here, especially to the women we treat, I would like to leave you with what I think sums up a lot of things in this country. Recently, one of our dear guards was leaving to go and marry his fourth wife in some far away village. “Mohammed”, I asked as he walked past the tukul, “are you happy that you are getting married…. again?” After a short pause, as he appeared to look for something in the dust, he turned to me, smiled and said “I am very very happy… she is almost pregnant…”

Gerry Simpson, Kambia, 20th March 2004