Rebecca Searle / Paediatric Registrar / Mersey Deanery
Becky is an ST5 Paediatric Specialist Registrar in the North-West of England. After completing her professional membership exams she took an Out of Programme for Experience (OOPE) to complete a Diploma in Tropical Medicine and Hygiene (DTM&H) at Liverpool School of Tropical Medicine (LSTM). She also spent six months in Sierra Leone with the Royal College of Paediatrics and Child Health (RCPCH) Global Links Programme from September 2020 to February 2021.
“Pomoi, Pomoi!” The excited children scream as you walk around every dusty street corner, running up to you while being chased by chickens kicking up swirls of red sand. As a white British female, it is impossible to blend in with the locals in the West African country of Sierra Leone. “Pomoi” means “white man” in the local tongue of the Mende tribe, which dominates the tropical South of the country where I was working in Kenema, Kailahun, Bo, Moyamba, and Pujehun.
A story of the struggle of Sweet Salone
Sweet Salone, as it is affectionately known by the locals, is a small country that has been through a lot. The name was coined by a Portuguese explorer in the 15th century who mapped the hills surrounding the now capital, Freetown, likening them to lions.
Following its European discovery, it became a key West African trading point, harvesting Sierra Leone’s natural resources including gold, spices, and sadly thousands of African slaves. Upon the abolition of slavery, many displaced African and West Indian people were sent back to Freetown, the “Province of Freedom”, forming the Krio ethnic group leading to conflicts between the remaining local African chieftains.
Sierra Leone remained a British colony with ongoing trade between the British and the Krios in commodities such as sugar, tobacco, and diamonds, until gaining independence from the British crown in 1961. The parliamentary system, however, remained and many years of conflict between the two main political parties culminated in a civil war, raging the country for 10 years from 1991 to 2002.
The country fought hard to recover from the atrocities which took place during the civil war. Unfortunately, it was badly affected by the 2014 West African Ebola virus epidemic and then by a series of mudslides in the capital in 2017.1
After Ebola: capacity building in Sierra Leone
The Ebola crisis highlighted deep-rooted and long-running fragilities in Sierra Leone’s health system, which persisted despite several years of international aid. Following further research into building capacity in-country, the emphasis was shifted from building skills and knowledge at the individual and organisational levels to a more system-based approach considering politics and power.2
The Saving Lives in Sierra Leone project aims to improve access to and use of reproductive, maternal, neonatal, child and adolescent health services in the country. It is funded by the UK and implemented by the United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF) and World Health Organisation (WHO). The programme started in October 2018 and was planned to run through to March 2021.3 The RCPCH Global Links Programme is part of the Saving Lives project and was in its final phase of implementation when I joined as an International Mentor.
RCPCH Global Links and ETAT+
In my six-month placement with the RCPCH Global Links Programme, I joined National Nurse Mentors in delivering the Emergency Triage, Assessment, and Treatment Plus (ETAT+) Programme.
This programme is a WHO endorsed emergency paediatric care intervention, aimed at improving the ability of healthcare workers in resource-limited settings to identify and treat critically unwell children.4 This is similar in principle to Advanced Paediatric Life Support (APLS) in the UK. ETAT+ was initially developed in Malawi and has since been established as an emergency paediatric protocol in several African and Asian settings.5 ETAT+ has been delivered in Sierra Leone by the RCPCH since 2017 and has been associated with reductions in case fatality in Ola During Children’s Hospital, the tertiary Children’s Hospital in Freetown, from 12.4% to 5.9%.6
I was in Sierra Leone from October 2020 until February 2021, during the final phase of the programme. The emphasis then was handing over the programme to the Sierra Leone government and up-skilling the local nurses in the district government hospitals to continue to deliver the ETAT+ programme without the presence of RCPCH Global Links.
Life-saving lessons – from practice to pikin (child)
We worked with the incredibly passionate and skilled National and local Nurse Mentors to deliver a 16-week training program to a cohort of local nurses, healthcare assistants, and physician associates. At the end of the weekly taught programme the candidates completed a thorough written and practical examination before receiving their certificates of completion if they passed both components.
The candidates attended in their own time pre-and post-shift, around the competing demands of childcare, cooking, and cleaning for their families. It was a pleasure to teach the enthusiastic healthcare workers, keen to help the many sick children seen in clinical practice every day. It was encouraging to see the direct translation of skills acquired in the classroom to real-life scenarios: from less than half of the candidates achieving chest wall movement during bag-valve-mask ventilation of an infant mannequin to almost all successfully doing so independently, both on the mannequin and unfortunately in the many arrest cases seen in resus daily.
Kusheo (welcome) – the importance of pleasantries and the bigger picture
Small talk is taken seriously in Sierra Leone. At the start of every meeting, be it personal or professional, people would genuinely enquire as to the health of one another and their families and with a simultaneous joint Muslim and Christian prayer. As part of the RCPCH Global Links programme we attended monthly meetings with the hospital management team to discuss barriers to implementing ETAT+ in their hospital, focussing not just on the knowledge but also the practicalities.
Across the hospitals there were recurrent themes of drug stockouts (most commonly antibiotics and antimalarials); resource limitations (intermittent electricity/generator power and lack of clean water); staffing issues; and equipment inadequacies (no batteries for pulse oximeters, no glucometer testing strips or malaria rapid diagnostic tests). To overcome such issues, equipment such as cannulas, syringes, airway adjuncts, and oxygen tubing had to be re-used.
We also undertook quality improvement projects, such as creating a checklist and implementing daily checks of the Resus trolley. We collected data on morbidity and mortality; timings from gate to triage to treatment, and quality of care. Compiling this information, we created tailored Hospital Paediatric Improvement Plans alongside the National Nurse Mentors. Stakeholders were able to review progression across a range of key indicators to help with informed decision-making and local funding.
Conclusions – cultural context and decolonisation
I can’t emphasise enough the importance of cultural context when living and working in a country other than your own, particularly where colonisation has had such a huge part to play in its history. I think we need to be mindful and try to avoid the classical “white warrior” approach to humanitarian work and thus ongoing colonialism. It is often resources, not knowledge or skills, that is the limiting factor in these healthcare settings.
My six-month placement only scratched the surface and I would encourage anyone to spend at least this amount of time overseas in humanitarian work to help to contribute to a long-term change. Instead of “patching gaps” in the overstretched healthcare system (unbelievably there are more doctors from Sierra Leone practicing in Manchester than in Sierra Leone itself). Wherever possible try to choose a project focusing on local buy-in and longer-term improvements, with an emphasis on leadership from local people.
If you would like more information on volunteering with RPCH Global Links, please see their website for current opportunities.
References
- “Sierra Leone”. Wikipedia, 5 January 2022,https://en.wikipedia.org/wiki/Sierra_Leone
- “After Ebola: Why and how capacity support to Sierra Leone’s health sector needs to change”. Lisa Denney, Richard Mallett with Ramatu Jalloh, 1 July 2015, https://securelivelihoods.org/publication/after-ebola-why-and-how-capacity-support-to-sierra-leones-health-sector-needs-to-change/?resourceid=362
- “United Nations Population Fund”. https://www.unfpa.org/saving-lives-sierra-leone-phase-2
- “Updated guildine: paediatric emergency triage, assessment and treatment: care of critically-ill children”. 2016), https://apps.who.int/iris/handle/10665/204463
- “RCPCH Global 2014-2022. The evolution of RCPCH Global Programmes.” RCPCH, 2019. https://www.rcpch.ac.uk/sites/default/files/2019-02/rcpch_global_booklet_a4_20_web.pdf
- “Reductions in inpatient mortality following interventions to improve emergency hospital care in Freetown, Sierra Leone”.
https://pubmed.ncbi.nlm.nih.gov/23028427/ - “Life expectancy at birth, total (years)”. United Nations Population Division. World Population Prospects, 2019,
https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=SL
