Day 10

28.01.2015

Screams of a grieving mother break the morning calm.  Death is very visible here.  Every day, inside and outside the Ebola holding unit, patients die.  On most days a taxi will drive into the hospital with a corpse in the back seat; we carefully note “Dead on Arrival” in our large notebook of Admissions, Discharges, Deaths.  We bring the body into the holding unit morgue and obtain an oral swab to check for Ebola; a burial team comes to collect the bodies each morning. 

Grief is loud and public, and often involves a screaming female mourner physically restrained by others.  Frequently, the body of a patient that has died on the general wards is wheeled on a rickety hospital bed through the grounds to the mortuary. Onlookers rise to a stand, a silent gesture of respect, watching the corpse wheel by.

Those patients that survive to discharge from the Ebola holding unit often face enormous challenges.  Of course, Ebola is not the only illness here.  Cardiovascular disease, cancer, diabetes, and sickle cell are ever-present, as well as many other infectious diseases.  HIV, malaria, and tuberculosis are the Big Three, but many vaccine-preventable illnesses are now on the rise after almost a year of no public health interventions, including routine vaccinations.  Few hospitals are open; those that are function on a skeleton crew of young, often unsupervised, house officers. 

This week, we admitted a young woman to the Ebola holding unit for diarrhea, vomiting and malaise.  She looked chronically ill; HIV or TB seemed much more likely than Ebola.  She tested negative for Ebola, and was discharged. 

But she was still too ill and too weak to walk.  We requested a direct admission to the general wards.  “No beds,” came the expected response.  Pervasive fear of Ebola often makes it very difficult to obtain general hospital admission for patients discharged from the Ebola holding unit, even when they can pay.  And this patient, without family or financial means, could not. 

The young sick woman was left outside on a bench to pass the night. No beds the next morning either. 

Almost all medical care in Sierra Leone is ‘fee for service’.  Before a hospital admission, a registration fee must be paid.  Before the doctor sees a patient, a doctor fee must be paid.  Each tablet, each injection, each catheter, each lab requires a fee paid up front.  If there is no one accompanying the patient to advocate and pay for the patient’s needs, no treatment is provided.  More often than not, the nurses station looks more like a cashier’s desk, covered with bills and account books. 

In mid-morning, we are in the green zone ‘office’ when we hear a commotion outside.  Maintaining a safe distance, a small crowd has gathered around the young woman who is seizing on the cement floor, tonic-clonic movements, frothing spittle at the mouth.  Probably toxoplasmosis, cryptococcus, or TB meningitis.

I go back to the hospital senior staff to plead that the patient be immediately admitted for evaluation and treatment.  A bed suddenly materializes.  I write a careful referral form, recommending HIV testing, basic labs, chest Xray, sputum for TB testing, LP.  We start the complicated, protracted process of qualifying the patient for ‘destitute funds’, which requires tracking down senior staff for multiple signatures.  Two days later, the patient is receiving expensive antibiotics in the wards that she probably doesn’t need, the paperwork hasn’t been signed, and she still hasn’t had an HIV test. 

The obstacles to providing quality medical care here sometimes seem insurmountable. The needs are enormous.  The system and culture of the current healthcare system needs a fundamental change. 

The organization that I am volunteering with, King’s Sierra Leone Partnership, was created to strengthen the healthcare system in Sierra Leone through long-term partnership with local leaders and healthcare providers to develop organizational structures, resources and commitment to improving health.  

I believe that consistent efforts driven by this philosophy can achieve the seemingly impossible goal of delivering quality healthcare here.  But each day toiling toward that goal is a challenging and heartbreaking process.