Complications (Part 2)

Connaught Hospital is the principal government hospital serving Freetown; it provides medical and surgical care to the local population and is a tertiary referral centre for the rest of the country.  There are around 300 beds and the vast majority of admitted patients will pass through the emergency department.  Patients that require admission are often incredibly sick, and the medical staff, many of whom are volunteers often work under challenging circumstances.  I’m constantly impressed by their positivity and eagerness to do the best for their patients, despite the resource limitations and lack of critical infrastructure that exists within the healthcare system to manage the high burden of disease here. 

Malaria is incredibly common; the WHO World Malaria Report quotes a figure of 1.7 million cases in 2013 (in a population of 6 million) with over 4000 deaths.  The prevalence of HIV is quoted as around 1.5% although the hospital prevalence is likely to be higher; many are newly diagnosed when they present with advanced features of the disease, such as disseminated TB and neurological complications such as toxoplasmosis and meningitis.  In addition to the ‘big three’ infectious diseases of TB, HIV and malaria; tetanus is not uncommon and typhoid is a fairly frequent diagnosis, although the diagnostic limitations currently make this a difficult disease to confirm.

I was expecting a high burden of infectious disease in Sierra Leone but I have been surprised by the significant degree of morbidity caused by non-communicable disease, much of which remains undetected and undiagnosed.  Patients are not generally screened for diseases such as hypertension and diabetes and many are often only diagnosed when they present with a complication such as a stroke, heart failure or diabetic coma.

 

The other main group of patients that present frequently to A&E in Connaught are victims of trauma.  Injury accounts for 8% of all deaths in Sierra Leone and the reasons for such a high figure are multi-factorial.  Road traffic collisions are common and vehicle safety often inadequate; it is a rarity to find a public vehicle with functioning seat belts.  Motorbikes weave in and out of traffic on narrow crowded roads, dodging around unwary pedestrians; many riders do not have helmets, let alone protective clothing, and it is a rarity to see their passengers wearing one.

Emergency care is a small, but increasingly important part of the overall picture.  The healthcare system is fragile and vulnerable, as recent experiences have proven.  In 2012, there were only 185 doctors serving the entire country and half the country’s healthcare workers were based in the capital.  This was pre-Ebola.  Poverty is common and the cost of care and hospital admission may bankrupt a family.  In 2010, the government introduced the Free Healthcare Initiative with the aim of reducing maternal and child mortality rates and making progress towards the Millennium Development Goals.  By offering free care to pregnant women, new mothers and children under 5, the country was making progress in improving what were some of the worst mortality rates in the world.  The situation is undoubtedly worse now, however, the country is beginning to look forward again.

The government have updated their Basic Package of Essential Health Services with a focus on recovery and building a resilient health system.  The goal is to provide efficient, cost-effective care that is available to all Sierra Leoneans and it recognises Emergency Care as one of the essential services.  There will be a major focus on maternal and child health but many of these deaths can be prevented by timely and effective emergency care.  Emergency systems strengthening, including pre-hospital care will improve outcomes for acutely sick and injured patients throughout the country but it will take time and effort.

 

Each patient described previously is based on a real case, and each has led to a great deal of reflection on how their outcomes could be improved and how their presentations could be prevented.  It can feel a little overwhelming at times.  I am developing a greater insight into how health systems function in general from my experience here, and gaining an appreciation of how challenging it can be to make changes that will have significant impact.  I have been in Sierra Leone for 3 months now, time is passing quickly and I am still ascending a steep learning curve.  Healthcare is a complicated business!