Learning through doing – making sense of a new cultural context

Dr Helena Posnett arrived in Freetown on 1 July to work for Marie Stopes Sierra Leone as Voucher Programmes Advisor.

With thanks to the Kailahun Outreach Team - you made me welcome and taught me “plenty plenty”.

Hello, I’m back and I’m excited to be writing again – this time from ‘up country’ in Kailahun District where it’s 40 degrees and I have three hours’ generator electricity per day, bucket water and sometimes the best wifi yet! Alongside a Marie Stopes midwife, I am on a quality assurance visit to an outreach team which delivers a mobile ante-natal clinic and partners with a maternity hospital.

NGOs are few and far between in Segwema. This means no café or restaurant but I am being looked-after spectacularly by colleagues who share their breakfast and supper with me, daily. It’s more peaceful here than Freetown and I have time to write…

Colleagues here tell me I’ve experienced a year of Sierra Leone in three months. You may remember, I wrote previously of the expat mantra “just don’t get sick”. Well, just as the blog was being published, I was in fact accompanying a British colleague on her 18-hour med-evac to South Africa where, thankfully, she recovered.

A fear realised? A nightmare come true? In many ways, yes. There is no doubt that healthcare provision in Sierra Leone is weak and no amount of medical insurance will change that. My colleague fell ill (and in a foreign country without long-term friends and family to support) and she experienced first-hand the very best healthcare there is and the dedication of professionals who wish to deliver ‘best practice’ in a heavily resource-constrained system. It was very frightening at times and one of the lowest moments was in an ambulance rocked in anger by a crowd whose taxi had been clipped by our wing mirror...

That said, many of the challenges we faced stemmed from our expectations, and we simply had to learn to navigate a healthcare system that was ‘different’ to the UK:

• To negotiate the waiting room – first come first served, no matter the condition
• To get hold of cash and lots of it - to pay upfront for investigations and treatments, item by item; and without it, no care
• To bring in soap and a clean towel, focus on the clinical care and ignore the aesthetic
• To arrange for prescribed drugs to be bought in - when the hospital pharmacy did not stock them.

Now, several months on, one positive thing that will remain with me is the outpouring of love and support my colleague experienced from her Marie Stopes colleagues and Sierra Leonean friends.

The need to understand, embrace and adapt to ‘difference’ – the cultural context - is part of my daily life here and exemplified on this trip to the field.

I’d certainly consider myself an adventurous traveller and have always been open to simple living when on holiday. However, after the relative workplace comfort of Freetown, the lack of aircon, lighting, a cold drink and reliable electricity to charge my ‘companions’ (iphone, ipad, kindle etc.) has quickly lost its appeal!

This is the reality of delivering a healthcare service in rural Sierra Leone. On a daily basis, the outreach team is offered (from the chief in the village they are in) a different house which they adapt into their clinic, making use of the house layout (mindful of confidentiality), hand washing buckets with chlorine, natural light and, where possible, a breeze. Not easy.

Throughout the day, guided by my monitoring checklist, I would observe, ask questions and listen to translated answers – first from Mende (the local language) to Krio (national language) and, if I don’t understand (I’m getting better!), back to English.

Even, the expected ‘similarities’ – for example, the emotions of a healthcare setting – are different. Here, I find my responses far more extreme:

• Pride – witnessing nurses work devotedly and tirelessly as a team to unload the vehicle, set up a clinic, deliver their service and load up at the end of a long day
• Wonder – watching an educational session  with expectant mothers, many with young babies in arms and toddlers at their feet
• Sadness (and anger) – meeting a young client living in secret with a fistula for fear of being shamed by her partner or community
• Sadness (and hopelessness) – meeting a client with likely advanced ascites who had believed herself to be pregnant, knowing her treatment options will be limited
• Joy – meeting a client with kyphosis (from spinal TB) and newborn child, able to have a normal delivery second time round

By 5pm, we pack up and head home via the market. I am exhausted by the heat and experiences of the day and head to my guesthouse to send a few emails. The team, however, drives out again with ‘jingles’ on the megaphone to alert the community to the next day’s clinic. Resilience is the word that comes to mind.

The week ends with a feedback session at my guesthouse – now my ‘home’ in spite of all the challenges I found on Day 1. I have adapted and, critically, I returned to Freetown with valuable insights about the realities of delivering a healthcare service but was much in need of a debrief.

Time is flying and it won’t be long before I’m back in the UK and I’ll be reflecting from a different perspective. There will be plenty to ponder – those elements I’d like to ‘bring home’ and those I’ll be comfortable to leave. One question I will be asking relates to the generosity I’ve witnessed and experienced here - patience, time, love and care. Culturally, would we do the same back home for overseas visitors? I’d like to think so…