One night, not too long ago, four children died in the emergency room at the Children’s Hospital. Two of them had been sick for more than two weeks before coming to the hospital for treatment, and sadly both children died within a few hours of admission. They had simply come too late.

Day after day in the emergency room at Ola During Children’s Hospital, Sierra Leone, parents arrive with extremely sick children, often on the verge of death. It is not uncommon for a mother to come in with a child gasping for breath, or a child who looks “paper white,” or is unconscious, or with very cold extremities who is in shock. Occasionally they even come with a child who has (unknowingly to them) died en route. It is tragic.

Why are these children reaching the hospital so late? Is it ignorance or a lack of knowledge? Do they not realize how sick their children are until it is too late? Or is there a financial barrier? Health care is now free for children under five years old, but it could be the cost of transport that creates a barrier, or a family’s loss of income during the time they are in hospital. Maybe people don’t know about free health care. Or maybe it is inconvenient to come because the mother has other children at home. Are there other family pressures that keep them from coming to the hospital? Or is it because you can buy any medication you want at pharmacies located on every street corner? Is it due to traditional beliefs embedded with witchcraft and other (in our minds) bizarre ideas? It could be because the family thinks the child is “country sick” and in need of herbal medicine, rather than “hospital sick” and in need of “western medicine.” Is it because of the hospital’s reputation of children dying here? I suppose it is probably a combination of these things, and more, and to be honest it will be difficult to ever really find out.

I had hoped that with the introduction of free healthcare for children under five years old, parents would come to the hospital sooner rather than later. Ideally they should come to the hospital when the child is mildly or moderately ill and get treatment at an earlier stage. For many, that just does not seem to happen. But it could be a case of children who would have otherwise died at home in silence are now accessing the hospital in the final hours of their illness. It is hard to know.

Really, the majority of the children coming to the hospital have treatable diseases like malaria, pneumonia, anaemia, and diarrheal disease. These are all diseases that can be cured if treatment is started on time. But in the cases in which treatment is delayed, unfortunately the chance of survival plummets. We do what we can, with our limited resources but often cannot save the children coming in so late. Of course, our (emergency) care needs to be improved. I will not deny that, but I also know that if some of these children would show up at a hospital in the developed world, they would not survive either. Sometimes they are just too sick and close to death.

So what can we do? If only we had more insight into why children come to the hospital so late. Maybe if we understood why families are not coming to the hospital quickly we can look into ways to remove the barriers and encourage a change in behaviour. Maybe with some more time and results from a survey on health seeking behavior in nearby communities we will have more of an idea. Time will tell. For now, we need to continue to improve the services at the hospital so that optimal care can be given. We all need to try even harder, stay motivated, and work together in order to give these children the best care possible in this challenging setting.

Sandra Lako is a doctor from the Netherlands who previously spent four and a half years in Sierra Leone setting up and managing a pediatric outpatient clinic with an organisation called Mercy Ships. After a year at home, she returned to Sierra Leone to volunteer as medical coordinator with the Welbodi Partnership, a UK based charity supporting the only government-run children’s hospital in a country where 1 in 5 children do not reach the age of five.