By Naoise Todd, EUAV and nurse in Sierra Leone.

After gaining a range of experience as a nurse in different hospital settings, the EU Aid Volunteers project was the opportunity I had long been searching for to get some legitimate experience in the field of humanitarian and development work, which has always been my goal. The vacancy with Médicos del Mundo in Sierra Leone really attracted me as I had developed an interest in the country after following the Ebola outbreak in 2014, how the already exhausted health system had lost many of the few doctors and nurses to Ebola. I wondered how the fragile health system managed with so few qualified health professionals, which today remains to be an area of concern, as globally, Sierra Leone has one of the highest mortality rates of children under five and of pregnant women.

My deployment was in the welcoming town of Kabala, in the rural northern region of Koinadugu. The people, especially children, are always so friendly and curious to see a new face. Strolling along, many people will ask you to be their ‘padi’, krio for friend, as you greet them in passing. Along with being a very friendly place, Koinadugu is a beautiful hilly region, yet the terrain poses as a great challenge in terms of accessing health care. The main opportunities for income are agriculture, mining and the timber logging industry, which has been rapidly growing over recent years. Hundreds of young men, many even in their young teens, come from all over Sierra Leone and even Guinea to seize a rare opportunity of work. Yet these ‘timbers’ work in very difficult conditions and many regret the impact this work has on the environment. It is devastating to drive through the luscious green lands of this beautiful region and witness huge areas that have been flattened, victim to deforestation. Every day, multiple truckloads of timber exit Kabala to be brought to the ports of Freetown and exported to other countries who will ultimately make the profit. The locals tell me how Kabala is known in Sierra Leone for its pleasant cool climate, but since the timber industry took off this region has become much hotter in recent years, with markedly less birds and other wildlife. After hundreds of years of brutal colonisation and exploitation of the people and the land, the country sadly continues to be drained of its resources. The profits of these lucrative industries are not benefiting the people in any way; the primary health centres and hospital are overwhelmingly under resourced and a massive dependency on aid exists.

My role was based mainly in the District Health Management offices with the two District Health Sisters; two senior nurse managers with training in Public Health. They have the responsibility of managing, supervising and mentoring staff of the 49 health facilities within the district; one district hospital and 48 primary health centres. Most of the facilities are very basic. On my first day working with the District Health Sisters, I attended the monthly meeting of the ‘in charges’ of the health facilities in Koinadugu. All staff members presented the main challenges faced in their health centres. Of course, these were all areas that we massively take for granted every day in European healthcare settings; no water supply, no electricity, unsuitable/ non-functional waste management system, inaccessible roads, poor transport availability for referring patients. Despite being in the midst of such frustrating topics of discussion, everyone was up dancing their way to join the queue for lunch once the music abruptly began to blast in signal that the break had begun!

In my first weeks, I joined the district health sisters on supportive supervisions of the health facilities and had the opportunity to witness first-hand the challenges mentioned at the ‘in charges’ meeting. The enormous responsibility held by the health staff became apparent. Most of those working in the primary health centres are lower cadres of nurses with a basic two-year training background, often working alone in very isolated areas. The nurse we met at the first health facility had been working for almost two years after her training without receiving a salary. Unfortunately, this is the norm for many nurses, and worker from any sector for that matter. During the visit to this health facility, a young mother arrived with her small infant, approximately 7 months old, who was struggling with very laboured, very fast breathing. This presentation was worrying, and the baby needed close observation and immediate treatment. After the nurse administered an injection of antibiotics, she had to spend some time to convince the mother to bring the child to the local hospital for the required treatment; almost two hours’ drive away. This would be an expensive journey and meant that the mother would have to leave her other small child and her work on the farm. There would be no provisions or support provided for these costs or for her loss of income, except the help of the community who are always sure to look out for one another; an aspect of society that remains so prominent in Sierra Leone.

Towards the end of my deployment, I had another opportunity to visit some health centres; this time to assess infection prevention control and readiness in relation to the Covid-19 pandemic and the potential for another Ebola outbreak. I felt despair upon visiting the ill equipped facilities as the nurses reported even greater concerns now that the rainy season had started. The absence of a reliable water supply remained, yet now the nurse must walk to collect water in the pouring rain (one nurse had to walk 40 minutes to get water). Most facilities had holes in the roof, leaking water into the clinics and very often in the nurses quarters (many nurses even live within the health centres in a small room). Médicos del Mundo plans to rehabilitate some of these facilities and fix the roofs, though the nurses voiced concerns that this work could not be done properly when such heavy rains were already falling every day. If a woman developed complications during labour and needed referral to hospital, the journey will take much longer due to the poor conditions and flooding of roads, inevitably leading to maternal deaths, which occur at increased rates during this difficult season. Waste could not be burned as the allocated burning pit area was wet, causing risks associated with build-up of hazardous waste. Outdoor screening areas were non-functional in the winds and rain meaning potential Covid or even Ebola cases could enter directly to health facilities with risk of spreading infection. Stock outs of PPE were reported in every facility visited yet many of the ‘in charges’ could not reach centralised stores in Kabala to request restock. Some nurses reported having to assist women to deliver babies without gloves. Malaria cases were increasing yet the fierce weather conditions will deter many from seeking the medical help needed. At times, I felt overwhelmed by so many challenges and often questioned the efficacy of interventions carried out by NGOs, but above all, I felt respect to the health workers who continue to work in such demanding conditions.