Happy World AIDS Day!

Our infectious diseases volunteer Hannah unravels the complex picture of HIV in Sierra Leone and explains how KSLP are supporting the National HIV/AIDS Control Programme to improve diagnostics and testing.

 

Happy World AIDS Day. Maybe an odd thing to say on a day that commemorates a disease which has killed 70 million people worldwide. But despite the ongoing tragedy of the HIV pandemic, in 2017 there is lots to celebrate.

While a vaccine or a cure remain distant prospects, we now have incredibly effective treatment for HIV. Antiretroviral therapy (ART) can suppress the activity of the virus in the body to the point that it is undetectable and people show absolutely no symptoms or signs of the disease. Many people living with HIV can now take a single, well-tolerated pill each day, and live a normal healthy life. Perhaps even more impressively, we now understand that people with HIV who are taking effective treatment with a suppressed viral load cannot transmit the virus to other people.

With such powerful weapons to fight this disease, reversing the growth of the pandemic now seems possible. UNAIDS has adopted the ambitious 90-90-90 targets – that by 2020, 90% of people living with HIV should know their status, 90% of those should be on treatment, and 90% of those on treatment should have a suppressed viral load. This has driven a huge global scale-up of ART provision, and data from severely-affected countries such as Swaziland is beginning to show the benefits.

So what about Sierra Leone? In Western Africa the picture is complex. On the one hand, fortunately, levels of infection have not reached the levels seen in Southern and Eastern Africa. Sierra Leone’s 2013 Demographic Health Survey found a prevalence of 1.5%, with up-to-date results due in 2018. However, the lower burden of infection means that HIV has previously been afforded a lower priority and less international donor support than in other countries. There is an increasing recognition that Western and Central Africa are being “left out” of the HIV progress seen elsewhere in the continent.

The problem is multifactorial. In the highest-burden countries, almost everyone will know a friend or neighbour who is affected by HIV, which has some effect on normalising the disease. In Sierra Leone, despite the support of counsellors and peer networks, the majority of people living with HIV have not disclosed their status to anyone, for fear of discrimination or even abandonment. As a result, many people believe HIV to be a rare problem, or one that is confined to certain marginalised groups such as men who have sex with men or commercial sex workers. Most sexually-active young adults do not perceive themselves as being at risk of infection, and condom use is low. Fear of HIV affects testing rates, while infected people who are hiding their HIV status from their families find it very difficult to access care and take treatment regularly.

While ART medications are provided free to patients through the Global Fund, people living with HIV face multiple other barriers to care. Limited human and physical resources mean that patients may have to travel some distance to an ART site, and the cost in time and money may be prohibitive. In the rainy season, it can be difficult for supplies to reach remote clinics and stock-outs may occur. This is particularly problematic because excellent adherence is required for ART to successfully suppress the virus. Missed doses because of stock-outs or financial problems, or interruption of care during the Ebola outbreak, can lead to irreversible drug resistance developing.

This formidable challenge means that many people living with HIV in Sierra Leone are not benefiting from prompt diagnosis and effective suppressive ART, and instead develop weakened immune systems and infections such as tuberculosis and cryptococcal meningitis. People living with HIV therefore make up a very high proportion of medical inpatients in Connaught Hospital, with associated high mortality.

Recognising the scale of the challenge facing Sierra Leone, in 2017 the National HIV/AIDS Secretariat launched the ambitious “Catch Up Plan”, which aims to rapidly scale-up HIV testing and treatment across the country. Along with other NGOs, KSLP has been working with the National HIV/AIDS Control Programme to support implementation of the plan.

As part of the national HIV Technical Working Group, KSLP members have been centrally involved in updating the 2017 ART Guidelines to reflec,t the WHO’s 2015 “Test and Treat” recommendation – that all people living with HIV should initiate ART, rather than just those who have evidence of a weakened immune system. We have also been supporting national training sessions on these new guidelines for HIV workers across Sierra Leone, mentoring and supervising staff in Connaught to ensure their implementation, and working on translating these guidelines into a more accessible format which can be disseminated by smartphone app.

In Connaught we have been working with the hospital management and HIV counsellors to increase testing through provider-initiated testing and counselling for patients attending the hospital. This strategy, which is recommended by the WHO, takes advantage of a person’s contact with health services to offer them HIV testing, regardless of the reason for presentation. This has led to a dramatic increase in the rates of HIV testing, particularly amongst medical inpatients. We support care for these inpatients through clinical work with the junior doctors and regular HIV ward rounds with Connaught’s clinicians, and by improving systems to promote access to important tests such as CD4 and TB screening. We are collaborating with a local infectious disease specialist to pilot screening for cryptococcal disease in HIV patients with advanced immunosuppression , and to learn more about the prevalence of cryptococcosis in Sierra Leone.

Treating HIV in Sierra Leone can involve witnessing a tragic loss of young lives when people present with very advanced disease. However, the amazing effects of the treatment mean that it can also be extremely rewarding. A few months ago, I reviewed a lady in her twenties who presented with speech difficulty and complete paralysis of the right side of her body. She had initially been diagnosed with a stroke, but when her admission HIV test was positive we decided to treat her empirically for cerebral toxoplasmosis, a parasitic brain infection seen in people with advanced HIV. The improvement was remarkable. She regained her ability to walk and talk, started ART, and now just has some mild hand weakness. I regularly bump into her and her mother waiting outside the physiotherapy department for her appointment, gaining weight and looking healthy.

In addition to individual success stories there is definite progress following the Catch Up Plan, on both concrete targets and more subtle indicators. When I first arrived in Sierra Leone in January I found many people reluctant to talk about HIV. Healthcare workers adopt euphemistic acronyms – RVS (retroviral syndrome) or ISD (immunosuppressive disease) rather than utter those other three letters. One of the aims of provider-initiated HIV testing was to normalise HIV as “just another disease”, like hypertension or diabetes. Now it feels like the dialogue is changing, with a noticeable increase in awareness and willingness to discuss the problem. Connaught’s young doctors are passionate advocates for their HIV patients, and gain a lot of knowledge and experience about HIV management. While there is still a long way to go in tackling stigma, it feels like people are talking more openly about it.

HIV progress starts with openness and advocacy. So, Happy World AIDS Day! Celebrate by telling one other person the news that people who are on treatment with a suppressed viral load live a normal healthy life and are unable to transmit the virus. We’re looking forward to continuing to work with Connaught and the National HIV/AIDS Secretariat to make that a reality for more people living with HIV in Sierra Leone.

Hannah and Dr Lakoh teaching a session on scaling up HIV services across Sierra Leone last week.

How can we make the patient with an individual disease more visible?

This blog post starts with an admission of guilt. Its 6:00 at Connaught Hospital and I have become accustomed to taking advantage of the early hours to slip into the clinical office to steal a little of the Kenyan coffee that a recently returned volunteer has brought. I choose the shortcut through Ward 9, where normally I pass past the 20 or so bodies lying in bed without a second glance. However, this time a patient becomes visible. I see them because they are illuminated by a doctor and a nurse, a few pieces of simple medical equipment, and the patient notes by the bedside. I hurry on, arm myself with a caffetiere, and check back in with the nurse in charge on my return to enquire about the patient in bed 14. “Low BP” is the curt response I receive back. Gentle probing reveals that the night nurses had performed their routine vital signs monitoring, and upon discovering a patient with abnormal vitals had asked a doctor to review the patient. These simple steps are a small demonstration of a system that we have been supporting to embed in the hospital, aimed at identifying the deteriorating patient. At the core of this, is an attempt to make the very sick patient visible.

How else can we continue to make the individual patient visible amongst the multitude of sick? A clear diagnosis helps. It enables patients to access resources, slot neatly into algorithms, and become pleasing to the physician’s gaze. This leads to a second admission: the personal (and I guess shared) frustration of clinicians unable to diagnose and treat patients in the manner we have been trained due to structural barriers. In a low resource setting where diagnostics are less available and patients often have limited resources to access diagnostics, this makes the easy win of knowing what to treat, how to treat it, and the satisfaction of having cured a patient much harder to come by. It often leads to these patients being labelled “generally sick,” and if a patient gets better or worse, it is hard for a clinician to judge what intervention may have helped or hindered. This creates an unstable foundation for developing our learning and for attaining that natural satisfaction of having helped a patient.

How can we make the patient with an individual disease more visible? This is partly about increasing access to diagnostics, and we are very lucky to welcome our new Laboratory Volunteer, Ed Choi, who is working with Connaught laboratory to improve the access to and quality of basic haematology and biochemistry diagnostics for all patients. Secondly, we can focus on improving diagnostics for specific high burden diseases. We are delighted to announce a new partnership with the National AIDS Secretariat, National AIDS Control Programme, and Global Fund providing funding to increase access to HIV Rapid Diagnostic Tests, improved HIV counselling and improved quality of care and staff training at Connaught. In a setting where stigma, difficulties in accessing services, and loss to follow up remain high, increasing the visibility of this group both at the individual patient level and at the broader policy level is key.

As clinicians in a high workload environment, we are prone to devote more of our time to patients who have a natural advocate for their care, normally in the form of a relative. In this setting, we recognise that relatives perform a much greater role than in higher resource settings; they act as both basic care providers and agents ready mobilise the financial resources patients need to receive care. Building on the successful experiences of employing referral coordinators and survivor advocates to ensure higher quality care for EVD survivors through the CPES programme, we have submitted a new bid to UK Aid Direct that focuses on providing patient advocates for those who do not have a relative to advocate on their behalf. This is complimented by ongoing work to solidify the destitute policy and support Connaught’s social worker Ini, to draw the gaze to this marginalised group.

And whilst patients remain the key focus we must also ask how do we make healthcare workers visible? Next month we will see the roll out of a nursing newsletter highlighting the impact of individuals as they continue to innovate to improve care. This month KSLP Volunteer Danny McLernon-Billows supported the first induction session for newly graduated house officers working within the Teaching Hospital Complex. This event was not only key for knowledge transfer and orientation, but also an opportunity to ensure that these young professionals are more visible. Small tokens, such as ID badges, engender a sense of belonging. Larger gestures, such as the provision of a forum that encourages feedback and incorporates them in to the decision making processes of the institutions they are joining, increases their visibility, participation and is key to driving systemic change.

– Dr Daniel Youkee, Country Director

New Year, New Partners, New Opportunities

By Dr Daniel Youkee, Acting Country Director

As the new year begins, I first want to look back and thank Francis for his sterling work as Country Director. He managed the growth of the organisation, cemented our internal policies, and maintained close relationships with our Ministry of Health partners.  He will be fondly remembered and we look forward to working closely with him in his new role as Country Director for Restless Development Sierra Leone.

January also marks the last month of the Infection Prevention & Control (IPC) grant. The team has been working tirelessly to protect patients and health workers across Connaught, King Harman Rd, and Lumley hospitals. While the achievements of the IPC programme are immediately recognisable – visitors line up to wash hands, gloves sit neatly on the ward round trolley, and water flows from taps – what impresses most is the way in which progress has been achieved. There are now fiercely independent IPC focal points and we are seeing our staff draw back and Saloneans step up in the gravitational dance of partnership.  A huge thank you to Natalie, Hannah and all of you who worked on this grant previously (Sachiko, Dominic, Annabel, Ambrose, Gilbert, Becca).

As the IPC project winds down, we are gearing up to focus on a new 20 month (~$800k) mental health and neurology project. Funded through John Snow International, this will develop mental health services nationally, provide a pathway to accreditation for mental health nurses, and develop the neurology training and services available at Connaught Hospital. Hannah and Hege are working hard to ensure that the KSLP ethos is embedded throughout all elements of the programme design and to ensure maximum impact of the grant.

Over the past three months we have witnessed tangible gains across the hospital – from the implementation of the country’s first viral load monitoring in the Connaught HIV clinic, the regular Quality Improvement Committee meetings starting to deliver system change, the arrival of surgical trainee residents, the development of antimicrobial guidelines through consensus, and supporting our partners in the roll out and quality assurance of national malaria treatment guidelines.

The team based approach to Sierra Leone Early Warning Scores (SLEWS) implementation continues to integrate our work from undergraduate through to postgraduate education. SLEWS drives the recognition of and response to acute illness, improves communication between nurses and doctors, and supports the development of an ICU outreach service. SLEWS is the vehicle for driving improved patient care and health worker accountability and is a key component of KSLP’s framework for achieving behaviour and system change. On the ward trainings are bridging the gap from theory to practice and will culminate in the hospital-wide SLEWS launch on Thursday 27th January.

Internally, we continue to increase our engagement and alignment with KCL, with Martha, Max, Steve and Molly strengthening and developing our financial and recruitment processes.  Academic engagement with KCL appears to have reached a critical mass, with ongoing joint research proposals ranging from surgery to HIV, and from stroke care through to epidemiology.

Finally, we are entering a new era of partner relations as the Teaching Hospital Complex Act draws the College of Medicine and Allied Health Sciences (COMAHS) together with the four tertiary hospitals in Freetown under a new Nigerian-led administration. Autonomous from the Ministry of Health and Sanitation, it is a radical redesign of existing governance structures. We welcome Dr Deen as the new Medical Superintendent of Connaught Hospital and salute Dr TB Kamara for his long and distinguished service as he moves to take the role of Postgraduate Training Coordinator. As an academic health science centre partnership, we are uniquely poised to support our partners to seize this opportunity and drive sustainable system wide change.

#anotherdayatKSLP

As the KSLP team has grown over the years, our work has expanded to include activities across a wide range of programme areas. These activities are unified by the overarching vision of the partnership: to work alongside local partners to build a strong and resilient health system in Sierra Leone. We showcased the breadth of our partnership’s work in a month-long social media campaign #anotherdayatKSLP, the highlights of which you can see in this photo essay.

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New Developments, by Richard Lowsby

It has been a turbulent few weeks; the country’s leader has resigned and been replaced, senior politicians have been stabbing each other in the back and the opposition are in turmoil.  The population are divided after a bitter referendum, promises have already been broken and the rest of the continent look on in concern.  The health system is in financial crisis with concerns over sustainability, resources are stretched to the limit and morale is at an all-time low.   Patients are suffering and the staff that care for them are engaged in a battle with the health secretary with no signs of a resolution or solution.  I refer of course, to the UK and not Sierra Leone.

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Dr Rich Lowsby with final year medical students, photo by Ibrahim Kabia

I have been home for a few weeks, a trip slightly longer than planned, but have left the political turmoil behind and now arrived back in Freetown to experience the full assault of the rainy season. Gone is the dust and in its place, a damp humidity but at least it is slightly cooler now.  The large majority of my time before leaving last month was spent supporting the development of the hospital’s new acute surgical and trauma assessment unit.  This was the second phase of the new A&E development following the opening of the new department in March.  The unit opened while I was away and I am keen to see how it is going.

I was told that the ward had opened in a bit of a hurry when several seriously injured patients arrived simultaneously following a major traffic accident.  The staff had coped admirably and had continued to do so.  The sister and staff nurse in charge have the ward running smoothly, there is a list of responsibilities for each nurse on duty for each shift of the day.  Each bed has a chart on the wall above it with a plan for the patient.

The high dependency bed currently has a patient being monitored and provided with oxygen after admission for a gunshot wound and collapsed lung.  The lung is now re-inflated after placement of a drain and he is improving.  A patient with a significant head injury has just arrived in the trauma resuscitation room after an assault and the staff are assessing him, supported by the medical officer.  The surgical team are reviewing patients admitted overnight after their morning meeting, a man with a suspected perforated ulcer and a child with an infected wound after a snake bite may need to go to theatre.

Some of my colleagues have been conducting training to support the opening of the ward and have worked tirelessly alongside the staff to ensure it functions effectively.  I am thrilled to see how things are progressing and I have realised how important good relationships and team effort are in moving things forward.  Work initially began over 6 months ago and is now complete, the hospital has a new Emergency Department.  This has been in the planning for a while, well before my time and I feel fortunate to have played a part in it.

It is not only hospital management, doctors and nurses that have contributed, but we have been working alongside builders, biomedical sciences, cleaners, engineers, infection control, hospital stores, maintenance, Ministry of Health and Sanitation as well as the UK Department for International Development.  As a result of everyone’s efforts, the hospital now has a department that is geared to assessing and managing acutely unwell and injured patients, that staff can be proud of and patients can trust.  It is everyone’s responsibility to sustain this good work.

Published, with permission, from Dr Rich’s Lowsby’s blog, Sierra Leone Emergency

Enhancing Resilience: supporting the next generation of health workers in Sierra Leone

Freetown’s College of Medicine and Allied Health Sciences (COMAHS) was forced to shut its doors for nine months during the Ebola outbreak. Finally reopening in June 2015, COMAHS is critical for rebuilding Sierra Leone’s health workforce, despite its limited training capacity, poor learning facilities, and a major shortage of teaching staff in most areas. This essay tells the story of the partnership between COMAHS and KSLP, formed with the goal of building capacity and resilience in post-graduate education in Sierra Leone.

All photos © Katherine Wise/Momenta Workshops 2015

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A Day in Connaught Hospital's Intensive Care Unit

Today we are in the Intensive Care Unit (ICU) at Connaught Hospital where the nurses are conducting their afternoon handover. Alongside Sister Elizabeth Kamara, the ICU sister-in-charge, KSLP’s Dr Ruth is leading today’s handover.

DSC_0071 It’s is a quiet day in ICU so Dr Ruth is taking time to test everyone’s knowledge on the importance of fluids and how to provide oxygen. Her energy is contagious as she asks about each patient:

“Ok, so why might this patient’s condition have changed?”

“Fever?”

“Chest Infection?”

“Reaction to the blood?”

“Exactly, it could be any of those things, so if there is a change in the patient condition, we need to think about what might be the cause and what you need to tell the doctor in charge.”

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ICU sister-in-charge, Sister Elizabeth Kamara,

Such on the job learning is highly valued in this unit. The daily handover is appreciated as much for ensuring the consistency of patient care, as it is for the opportunity to receive further training.

“Mentoring other nurses is the best part of this job,” said Sister Elizabeth. “It’s great to be able to share my knowledge and understanding with others.”

A close relationship builds between the nurses and their patients. In ICU, they provide ‘complete nursing,’ which includes everything the patient like feeding, fluids, and pain management. Any and every change in the patient’s condition must be recorded. This is a major responsibility, but all of the nurses shoulder it professionally.

DSC_0015 Each provides a detailed history of every patient at the end of the shift. Histories include details of why the patient was admitted, when he or she was last seen, and the critical points in his/her care and management. Despite seeing some tragic cases, optimism abounds in the unit. After all, “ICU is where we treat critically ill patients,” said Sister Elizabeth. They are the ones we know we can revive again and bring back to life.”

From Ebola Isolation Unit to Modern A&E Unit: Transformation at Connaught Hospital

KSLP Emergency Medicine Doctor Rich shares his reflections on the recent A&E refurbishment at Connaught Hospital

The entrance doors were unlocked, revealing dark corridors and empty rooms illuminated only by slivers of sunlight stretching out across the bare floor through broken panes of glass.  My eyes struggle to adjust, pupils dilating as I peer into the shadows. It’s humid and I can already feel beads of perspiration forming at the back of my neck.  The tiles have faded after repeated dousing in chlorine and a fine layer of dust has settled to give the ward an eerie, long-abandoned feel.  This was once part of the red zone, a place of fear and tragedy for many, a place where local staff worked alongside foreigners doing the best they could in a period of great uncertainty.  It is now silent, no one has been here for quite some time.

By the time the epidemic reached Freetown, hundreds of cases a day were being diagnosed across the country and the staff at Connaught needed to act fast to establish an Ebola isolation unit in an attempt to contain the virus and protect its healthcare workers.  Prior to the epidemic King’s had a program in place to help strengthen the emergency services at the hospital and had already introduced a triage system to expedite assessment of the sicker patients that presented to the hospital.   The outpatient department was re-branded as the Accident and Emergency unit to re-inforce the need for timely and effective urgent care for the critically ill and injured patients that attend there on a frequent basis.  An emergency that no one expected subsequently swept across the country at alarming speed and the Accident and Emergency ward was transformed into an Ebola holding unit.

In time, a purpose designed isolation unit was established alongside the hospital and the old unit, after decontamination, became redundant and stood empty; a dark reminder of painful recent events.  When I arrived, just over six months ago, we were isolating and managing suspect patients in the new unit.  I had heard some very upsetting accounts from colleagues, from both Freetown and abroad, that were around at the height of the epidemic and I struggled to imagine how challenging the conditions must have been. Before Christmas, it was opened up and I was able to enter inside.  Renovation work would soon be starting on a new A&E Department and I was curious to see what would be required to transform a place where the grief was still tangible into a facility that will aim to revolutionise emergency care for inhabitants of the city and beyond.

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Dr Rich working on the A&E refurbishment at Connaught Hospital

During the epidemic, the emphasis of the government and international agencies was focused out of necessity in containing the disease.  This was no doubt to the detriment of other health related issues.  Maternal and child mortality rates will have increased, surgery throughout the country was suspended and I have seen many HIV and TB patients that defaulted on treatment.  Most health facilities shut down but Connaught remained open, providing a much needed service to those that were sick but not suffering from Ebola.  The A&E, in its temporary facility, continued to deliver essential care at the front door, at great personal risk to the brave staff that served throughout.

We have seen the country declared free of Ebola twice now since I arrived and with recent cases in Guinea, it seems unlikely that the country will never see another case.  The skill and expertise now exists in Sierra Leone to manage the situation and gain control rapidly, the focus is now on re-building and strengthening the health care system.  This is now the main emphasis of the work of King’s at Connaught and of my role in the Emergency Department.  The lasts few months have seen huge steps forward in the delivery of emergency care and much of the credit should be given to my colleague Ling who has worked tirelessly over several years now to develop the A&E in conjunction with the hospital staff and Ministry of Health.

Before: the future A&E unit pre-refurbishment
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After: Dr. Ling stands in the newly refurbished A&E unit

The end of February saw work complete on the old isolation unit and the new A&E, along with resus and medical admissions units opened to patients. Equipment and patients were transferred seamlessly, coordinated by Sister Kamara, in under 2 hours and there was impressively no delay or impact on patient care and safety. Several of the staff came in early of their own volition to prepare the department and I was told off for being late by one irate nurse who had been there since 6am.

Ling is now back in the UK and is sorely missed by all the staff she worked with at Connaught, although she has left a strong legacy.  Several high profile figures have visited the department in the last few weeks including the deputy health minister, chief medical officer and chief nurse; all have been impressed.  The staff are revitalised and proud of their new department, they are eager to learn how to use the new facilities and equipment.  We have a new enthusiastic and motivated medical officer and Emergency medicine is enjoying a raised profile in Sierra Leone currently.  I’m sure that this is all having a positive impact on the care of the patients, who seem to be attending in ever increasing numbers. The big challenge now will be to sustain and build on this momentum and ensure that the ministry can support the hospital to develop systems and maintain a supply chain that will keep the acute care facilities functioning effectively for the benefit of the patients.

A lot has taken place over six months and a great deal more is to come. While work has the potential to become all-consuming at times, it is the down-time and the support of those who are close that is important to maintain a sense of balance and perspective. My personal highlight has been the visit of Alice, who arrived in Freetown last month as my girlfriend and went home as my fiancée. I was really pleased to be able to share my experiences and show her the highlights of what can be, at times, a beautiful country. In a place that offers tropical islands and idyllic beaches in abundance, I felt the most appropriate spot for a proposal would be in the jungle surrounded by howling chimpanzees. Fortunately, my gamble paid off and she agreed to marry me!

The Laboratories: a Perfect Representation of Both History and Change at Connaught Hospital

“Let me show you… So you take this cartridge, be very careful not to touch or damage the barcode when you put the sample in, otherwise it won’t scan. Then, we put 1ml from this vial in the cartridge and then place it in chlorine for 20 minutes. This kills anything from the sample that’s on the outside of the cartridge so when we put it in the machine it’s the deactivated virus being scanned.” We are in the laboratory department at Connaught Hospital and our colleague Mohamed is demonstrating how he uses the newly installed GenExpert machine donated by WHO to screen surgery patients for Ebola. This test, which takes only 90 minutes to process, can have a dramatic impact on the safety of both the surgeon and patients.

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Mohamed demonstrating laboratory techniques

The laboratory department is a perfect representation of Connaught’s history and change in progress. In one room sits the original Microtome machine from when the hospital was opened in 1912; it is still processing histopathology samples (sectioning) to test for conditions like cancerous or malignant cells.  In another room, Mohamed is running the fully modern GenExpert machine to screen patients for Ebola and HIV, as well as other infectious diseases.

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KSLP Labs Coordinator Billy in the Connaught Hospital Labs

Through Sierra Leone’s post Ebola recovery plan, we expect that the way labs operate will continue to undergo substantial changes. Billy, KSLP’s lab co-ordinator, will be working with the Labs team to drive improvements to help navigate this process.

Red Pigs and White Coats: A Freetown Vignette by B.A Sillah

While surveying the alley between the pharmacy and storerooms for a potential new main entrance, I pause to chase some unwelcomed guests from of the hospital grounds. Three pigs had wandered into the patches of grass and rubbish lying between the fence on Percival Street and the weathered wall of Ward 10. The rusting gates that enclose the colonial era compound could not deter the four-legged vagabonds, seasoned by years of navigating between the tin-roofed Kroo Bay slum dwellings below the cliffs our hospital occupies. After watching them scurry down the road for a while, I return to my work on this misty Freetown morning.

The afternoon’s responsibilities fluctuate at a moment’s notice. At times, I round the wards to recruit discharged patients for our daily focus groups. The next minute, I am either mapping out a new construction site or attempting to repair a CT scanner printer with only a ruler and German user manual to my aid. At the end of the day, I climb on the back of a motorbike, preparing to weave through gridlocked cars and potholes on the streets leading to my home in the hills. I playing a nightly game of “is this chicken or fish” at the dinner table and then walk to my balcony to watch the rays from the setting sun as they hit the exhausted-fueled evening haze enveloping the city below. Such is a day in the life of an intern with the King’s Sierra Leone Partnership at Connaught Hospital. For five weeks over Summer I worked at Sierra Leone’s main tertiary referral hospital between my first and second year of medical school at the University of Pennsylvania. Born the son of Sierra Leonean immigrants in the United States, my first journey to my ancestral home had been 23 years in the making. From the time I stepped off the plane at Lungi Airport to catch the aged ferry that steams across the bay toward city on the horizon, I knew I was in for a journey I would not soon forget.

Sierra Leone has been a country of fascinating contradictions and juxtapositions. Lively shantytowns lie in the shadows of sterile, towering mansions purchased during the recent mining boom. Traffic lights unused for decades dot the city among ruins of construction sites abandoned in the 1980s, haunting reminders of an era of prosperity cut short by eleven years of civil war. The bustling cities rapidly work to catch up with the modern world and just hours away lie timeless, untouched villages carved out of the jungle. My time in Freetown was more than I could ask both personally and professionally. King’s Sierra Leone Partnership’s unique relationship with the Connaught Hospital leadership and Ministry of Health and Sanitation offered a look into hospital management one could not experience in other settings. The group’s work ranged from clinical responsibilities, to researching staff/patient satisfaction, to strategizing for improved hospital operations and much more. The weeks of work culminated with a meeting with the Minister of Health herself to present our task force’s findings. Beyond the efforts at the hospital, I immersed myself in the energetic culture of Sierra Leone. I connected with family whom had only been faceless names and stories weeks before. The emerging expat community brought me together with like-minded innovators from around the world who are lending their expertise to Sierra Leone’s development. Afternoons of basking in the sun on miles of empty, untouched beach, wandering crowded markets, and chatting over a Star beer at a local bar gave glimpses into a way and pace of life I have not found elsewhere. All in all, my time in Freetown was the perfect way to spend the summer. I am already looking forward to my next trip to my new home. Swit Salone, a de kam!