{"id":2304,"date":"2010-06-01T11:33:53","date_gmt":"2010-06-01T10:33:53","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=2304"},"modified":"2010-06-01T11:33:53","modified_gmt":"2010-06-01T10:33:53","slug":"emily-spry-on-crowd-control-in-sierra-leone","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2010\/06\/01\/emily-spry-on-crowd-control-in-sierra-leone\/","title":{"rendered":"Emily Spry on crowd control in Sierra Leone."},"content":{"rendered":"

\"PikinI haven\u2019t written for a month, but that is certainly not because there hasn\u2019t been anything going on at the children’s hospital in Freetown.\u00a0Rather, it is the opposite. It is hard to sit and reflect when there is so much going on.\u00a0I’ll try to write up a few of the things from the past month that really stick in my mind.<\/p>\n


\nAs you know, one month ago Sierra Leone took a bold step and started to provide free healthcare<\/a> for children under 5, and pregnant, and lactating women.\u00a0As the only paediatric hospital in the country, with a huge deprived population on our doorstep, the children\u2019s hospital was always going to find itself very popular once user fees were removed.
\n\u00a0
\nNonetheless, 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.\u00a0 These brightly dressed\u00a0women (and the occasional father) all had babies in their arms or, more often, tied onto their backs with lappas.\u00a0Toddlers stood or sat on the paving at their feet.
\n\u00a0
\nThus,\u00a0the first issue for free care was crowd control.\u00a0We 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.
\n\u00a0
\nBut we hadn\u2019t quite foreseen how large the crowd would be or how keenly they would press on the doors.\u00a0 Our few security staff were taken by surprise and found it hard to cope.\u00a0 There were squabbles and even some physical fights when some mothers felt that others were pushing ahead unfairly.
\n\u00a0
\nWe were fortunate to have the services of the local policemen for the first week.\u00a0They were polite, helpful, and very tall.\u00a0 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.\u00a0 Hastily-constructed barriers (concrete blocks and bush poles) also helped to mark out where people were supposed to queue.
\n\u00a0
\nThe second issue was more difficult; the sheer numbers.<\/p>\n

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.\u00a0 But, we are told, people want to come to the hospital.
\n\u00a0
\nCertainly some people brought kids who were not sick; some apparently believed that talk of a \u201cbasic healthcare package\u201d meant that they would, literally, be given a package of goodies if they attended.\u00a0Some believed that they needed to register before a certain deadline to be able to use the free services in the future.
\n\u00a0
\nThere was cheating too; someone was arrested for selling drugs obtained by taking the same child to several health facilities.\u00a0 And there were the inevitable rumours that Guineans were coming across the border to take advantage (Every country\u00a0is suspicious of\u00a0its neighbours and Sierra Leone is no exception).
\n\u00a0
\nBut, as the days went by and the initial crush reduced slightly, most people brought their kids because they believed that they were sick.
\n\u00a0
\nThis is a pressing dilemma.\u00a0On 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.\u00a0 On the other hand, the hospital and its staff can only provide care of any quality to a certain number of patients per day.
\n\u00a0
\nFor 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.\u00a0 But eventually things have to return to a more normal level.\u00a0 The staff start getting exhausted and sick themselves.\u00a0Mistakes 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.
\n\u00a0
\nAlmost immediately, we decided that we had to start going through the queue and, based on WHO criteria, start sending only the \u201cpriority\u201d cases inside and advising the \u201croutine\u201d cases to go to their local health centre.\u00a0 Emergency cases went straight up to the ER as usual.
\n\u00a0
\nIt wasn\u2019t easy.\u00a0 These are people who might never have brought their children to government health services before because of the fees.\u00a0 And now they\u2019re being told that they can\u2019t come in to the hospital.\u00a0 We don\u2019t want to put them off; we want them to come back if their kid gets really sick.<\/p>\n

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.\u00a0Rather stupidly, I got sunburnt, standing out in the car park for so long.
\n\u00a0
\nIt 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.\u00a0 It\u2019s been an amazing experience but there is part of me that is\u00a0looking forward to just seeing patients again and dealing with one problem at a time.<\/p>\n

Emily Spry<\/strong> 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.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

I haven\u2019t written for a month, but that is certainly not because there hasn\u2019t been anything going on at the children’s hospital in Freetown.\u00a0Rather, it is the opposite. It is […]<\/p>\n

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