I’m excited to have started at the Ola During Children’s Hospital in Freetown, after hearing so much about it from the Welbodi Partnership, the charity I’ll be working for over the next year.

On first impressions, things at the hospital look good.  There are freshly painted wards and uniformed nurses.  There are notices on the wall:  “Drugs for inpatients are now free” (thanks to a German charity).  The outpatient benches are lined with parents and kids, waiting to be called into three consulting rooms.  The observation ward is full of children, one loudly fighting off the advances of a nurse brandishing a cannula.

But look beneath the surface, and you start to see the problems.  The Pikin Hospital (the name given to the Ola During Children’s Hospital in Krio, the lingua franca of Sierra Leone, meaning children’s hospital) has its outpatient department, three main wards and a newly-introduced intensive care unit.

The ICU would not be recognisable as such to those of you who are used to the hush of ventilators and the banks of machines that go “ping”.  “Intensive care” is defined by its relatively high staff-to-patient ratio, but it’s 4 nurses and 4 untrained nursing aides to around 30 sick children, all lined up cross-ways in 10 adult sized beds.  The only equipment is a lone oxygen concentrator, with tubing splitting the precious gas four ways, and an oxygen saturation probe to help doctors decide who gets to use some.

Around 10% of the children admitted each day die, usually within 24 hours of admission and usually due to severe malaria, anaemia, sepsis, dehydration, malnutrition or, more often, a combination of several of these.

After a while, you start to see what is lacking.  Sitting with the busy medical officers in outpatients, you realise that they have to make decisions without access to even basic investigations.  Those they can order, parents may not be able to afford.

As a parent, the odds are stacked against you.  The hospital charges a flat fee of 15,000 Leones (around 2.50 GBP or 3 USD).  This might sound trivial, but when more than half the population lives on less than a dollar a day, it’s a crippling cost for many.  Inpatient drugs are currently free but outpatient drugs must be bought and counterfeit drugs are common.

If you have four kids and one of them is about to cost you the family food budget for the month, it’s not an easy decision to make.  If your child has a chronic disease, such as sickle cell disease, and gets ill repeatedly, it’s not hard to see why you might feel unable to follow the doctor’s advice.

So, as soon as you start thinking about this your head starts spinning.  Everywhere you look, there are little things that might make a huge difference, things that it might be in your power to influence.  What if I went out right now and bought 30 thermometers?  What if we could find a way to get people to donate blood? What if we could find a haematological hero in the UK who would come out and set up blood screening?  What if I could persuade someone to donate an Xray machine?  What if I could train the nurses to recognise the sickest kids and act on it?  Where on earth to begin?

And then the doubts also bubble up to the surface.  Who will ensure that equipment is used properly? And maintained? What if things are stolen?  How would the government-employed laboratory technicians here react if someone tried to set up a parallel service to take away their only income?  Will giving the nurses and doctors more work to do really help?  Will my NHS-learnt ways of working actually be useful here?  Or would they upset a delicate balance that stops everything falling apart?  Can I realistically do anything here that will last after I’ve gone?  How can we decide the best way to treat kids here when we don’t even have basic diagnostic tests?  Could even the best hospital in the world help the children brought by their parents only when they are at death’s door?

Luckily for me, the Welbodi Partnership have spent some years building up their relationship with the hospital and refining an approach that combines their optimistic vision with the patience to grapple with the day to day limitations of the hospital.  My project is to set up a Triage system and an Emergency Room, to try to focus staff and resources on the sickest kids each day.  It’s going to be interesting…

Emily Spry is a doctor from London who has taken a year out of her General Practice Specialty Training Programme to live and work in Sierra Leone, West Africa.  She is working for the Welbodi Partnership, a charity which supports the main government Children’s Hospital in a country where more than one quarter of children die before their fifth birthday.