Emily Spry on crowd control in Sierra Leone.

Pikin HospitalI haven’t written for a month, but that is certainly not because there hasn’t been anything going on at the children’s hospital in Freetown. Rather, it is the opposite. It is hard to sit and reflect when there is so much going on. I’ll try to write up a few of the things from the past month that really stick in my mind.

As you know, one month ago Sierra Leone took a bold step and started to provide free healthcare for children under 5, and pregnant, and lactating women. As the only paediatric hospital in the country, with a huge deprived population on our doorstep, the children’s hospital was always going to find itself very popular once user fees were removed.
Nonetheless, I have to admit that I froze, my heart in my mouth, as I swung through the gates on the first day and saw the throng of mothers filling the car park.  These brightly dressed women (and the occasional father) all had babies in their arms or, more often, tied onto their backs with lappas. Toddlers stood or sat on the paving at their feet.
Thus, the first issue for free care was crowd control. We had rearranged the front entrance to the hospital so that there was a much larger area for registration and triage, with rows of newly-made benches, and wooden posts with string, festooned with ribbons in the national colours.
But we hadn’t quite foreseen how large the crowd would be or how keenly they would press on the doors.  Our few security staff were taken by surprise and found it hard to cope.  There were squabbles and even some physical fights when some mothers felt that others were pushing ahead unfairly.
We were fortunate to have the services of the local policemen for the first week. They were polite, helpful, and very tall.  Our previously-ignored instructions to the crowd (all babies under 2 months to come to the front, everyone else to form an orderly line etc) were quickly followed when these boys in bright blue turned up.  Hastily-constructed barriers (concrete blocks and bush poles) also helped to mark out where people were supposed to queue.
The second issue was more difficult; the sheer numbers.

The government free health care initiative includes all health facilities and there are numerous peripheral health units all over Freetown also charged with treating children for free.  But, we are told, people want to come to the hospital.
Certainly some people brought kids who were not sick; some apparently believed that talk of a “basic healthcare package” meant that they would, literally, be given a package of goodies if they attended. Some believed that they needed to register before a certain deadline to be able to use the free services in the future.
There was cheating too; someone was arrested for selling drugs obtained by taking the same child to several health facilities.  And there were the inevitable rumours that Guineans were coming across the border to take advantage (Every country is suspicious of its neighbours and Sierra Leone is no exception).
But, as the days went by and the initial crush reduced slightly, most people brought their kids because they believed that they were sick.
This is a pressing dilemma. On the one hand, there are a lot of sick kids in Sierra Leone who are not getting medical treatment, too many of whom die as a result; this was the motivation for the whole endeavour.  On the other hand, the hospital and its staff can only provide care of any quality to a certain number of patients per day.
For a few days, everyone can bust a gut, see a 70 patients, stay late into the evening, sweating it out in the outpatient consulting rooms.  But eventually things have to return to a more normal level.  The staff start getting exhausted and sick themselves. Mistakes increase, things get missed, no one has time to review the patients who are admitted to the wards because they are too busy admitting more.
Almost immediately, we decided that we had to start going through the queue and, based on WHO criteria, start sending only the “priority” cases inside and advising the “routine” cases to go to their local health centre.  Emergency cases went straight up to the ER as usual.
It wasn’t easy.  These are people who might never have brought their children to government health services before because of the fees.  And now they’re being told that they can’t come in to the hospital.  We don’t want to put them off; we want them to come back if their kid gets really sick.

Mothers who had queued for hours seemed to take the news surprisingly well from me, but many got angry with the Sierra Leonan nurses, saying that they were keeping the drugs for themselves and not allowing the people to have what they were owed. Rather stupidly, I got sunburnt, standing out in the car park for so long.
It is a world away from my last job in general practice in Mill Hill, North London, where there was not much chance of occupational sunburn.  It’s been an amazing experience but there is part of me that is looking forward to just seeing patients again and dealing with one problem at a time.

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.