My experiences in Masanga
Dr Louise Wade
I spent 4 months at Masanga Hospital from September 2012 to January 2013. I went out there as a
fairly junior doctor – having just over 3 years experience of working in UK hospitals behind me.
Masanga is a small village pretty much in the centre of Sierra Leone. The village is next to a river and
hidden amongst the forest. The hospitals’ origins were as a leprosy hospital and hence the location is
quite remote. Before my arrival I had received an induction and some basic information about the
hospital. It is a hospital of approximately 100 beds split into surgical, maternity and paediatric wards
and a stabilisation centre for malnourished children. There is also a busy outpatient department.
Before I arrived I understood that most of the time the hospital had no electricity, there was a large
generator which was turned on only for a few hours each night and when operations were occurring.
There was also no running water in the hospital with the exception of 2 taps in the operating
theatre. My experience being limited to having only worked in the UK I could not imagine how a
hospital with no electricity or running water would function.
In truth it is amazing how little you actually need to provide good, basic medical care. A couple of
weeks after my arrival I scarcely noticed the lack of running water instead getting used to using
alcohol gel or a bucket of water collected from the well to wash my hands. Indeed even in the hostel
where we lived a clever Danish volunteer had created a bucket with a shower head on it which could
be hoisted up to provide a surprisingly good shower.
As a doctor the learning experience in Masanga was incredible. I saw many conditions I had only
read about before – Lassa fever, tetanus and onchocerciasis to name a few. Patients often presented
much later than I was used to seeing in the UK, this meant that disease processes were much more
advanced and unfortunately sometimes that people were just much more unwell. I found one of the
biggest challenges for me as a western doctor was learning to work without the array of diagnostic
tools I am used to relying on. In Masanga they have basic blood tests, an x ray machine and the
ability to do some microscopy but that is about it. Once you adapt to this there is a lot you can do
and it was a good challenge for me to learn to use my clinical skills more rather than relying on say a
CT scan to provide a diagnosis. As a relatively inexperienced doctor seeing a range of diseases new
to me and learning to work in a very different environment could have been extremely difficult but
one of the greatest assets Masanga has is two Senior Dutch Tropical doctors. They have completed a
training program in the Netherlands which equips them with everything from the skills to do a Csection to a good understanding of tropical disease. They were an immense source of support and
knowledge to me throughout my stay and ensured it was not too daunting but an enjoyable learning
experience.
One of the most incredible things about Masanga Hospital is the local staff that work there. They
have a number of clinical health officers (CHOs) who have received 3 years of training and essentially
fulfil the doctor role. Despite having had only about half of the training time that a western doctor
would expect they are generally very competent. Often they were the ones teaching me about the
specifics of tropical disease or the WHO guidelines that they followed. However whenever there was
an area where they had not had the same training or knowledge as me they welcomed any teaching
opportunities. I have struggled sometimes with teaching medical students in the UK – it can be hard
to find a convenient time or to make it interesting for them and not something they have done
before. Teaching in Sierra Leone became such a pleasure as it was clear just how much the CHOs
enjoyed it.
Masanga also employs a large number of nurse aids and 2 fully trained state registered nurses. This
is an unusual situation as when I was there the hospital actually had almost twice as many doctors as
fully trained nurses. Masanga now has a nursing school on site though and this will be of great
benefit as it is hoped a number of the graduates will come to work in the hospital. The nurse aids
have also been trained on site, receiving 6 months of training, and all of them live in local villages. It
took me a few weeks after I arrived to appreciate how fantastic the nurse aids were. I noticed that if
I was there first thing in the morning or in the middle of the night I would often see the same faces
working and attending to the patients. At first I put this down to coincidence, but later when we
would have emergency patients come in I found you could see all of the nurse aids who were
employed on that ward in attendance at the same time. Whenever it was busy or something was
happening which they could learn from they would just come in from the village and do a few extra
hours work. They were never paid, or expected to be paid for this. The way they all rallied round
when someone was sick and we needed extra help was so impressive and made me question all of
the times I had moaned about having to stay a little late at work in the UK.
My main role in Masanga was to project manage the opening of a new Acute Admissions Unit for the
hospital. Masanga, and in fact most of the hospitals in Sierra Leone, had never had an Emergency
Department – something we consider fairly standard in the UK. When sick patients arrived they
would undertake often a long wait to be seen in outpatients before being identified as quite unwell
and admitted to a ward, or, if they arrived out of hours or self-triaged themselves as sufficiently
unwell, they would present directly to a ward for admission. The Acute Admissions Unit would
improve this process by giving emergency patients somewhere to go and creating a recognised
system for triage and admissions. It was also to benefit from a higher nurse aid to patient ratio of 1:4
allowing it to also function as an high dependency unit area for the most unwell to be cared for in.
On my arrival building work on the unit was nearing completion and my initial tasks were to help
with hiring staff, arranging the equipment we needed and making arrangements for and educating
others about how the unit would work in practice. We were fortunate to have our own separate
generator for the unit, it used much less fuel than the large generator which powered the whole
hospital site and therefore we could at times run it 24 hours a day. As we also had a new oxygen
concentrator received form the UK this meant we now had the ability to provide electric lighting and
oxygen at any time it was needed. These two simple measures greatly increased the standard of care
the hospital could provide. The unit opened about 3 months into my stay in Masanga and as per
local tradition a great opening ceremony was held.
One of the special things about Masanga is the community of Danish volunteers who come out to
help with the hospital. At any one time there can be anywhere from about 4 to 20 different
volunteers. They all come out with specific projects to work on – some of them are trained health
professionals such as midwives or nutritionists, others have business knowledge and help with
running of the hospital others still have engineering skills and help with projects such as trying to
develop a running water supply to the site. They bring a great energy and skill set to the project and
indeed I think the locals really enjoy having them. The volunteers all live in a hostel on the hospital
compound site and whenever new volunteers came or old ones moved on often a party was had.
These were always well attended by the locals although they were never too impressed by Danish
music and it was only ever a short time before it was replaced by music the Sierra Leonians felt they
could really dance to.
Finally a word about the patients who attend Masanga Hospital. The patients travel often huge
distances to attend as the hospital has a good reputation and the fees tend to be lower than at the
local governmental run hospitals. The make their own journeys, which can take several days, with
severe pain and with uncertainty as to whether help will be available for them. They then wait,
patiently and often for some time to be seen. When they are seen they are grateful for anything you
can do and are without fail polite and a pleasure to treat. If they are admitted each patient must
have a carer to stay with them. This is often a member of their own family who will stay with them,
bring them food and wash their clothes and sheets. If the carer is a young woman they will bring
their children too and you see these small subsections of families lovingly looking after each other
each day. In UK hospitals with structured visiting hours we sometimes we see little of a patient’s
family and lose out on this insight into their life and those that love them. It is easy for patients to
become “the gall bladder in bed 6”. Masanga hospital is busy and crowded but in a way that I
became very fond of.
My four months in Masanga were an incredible experience. I learnt so much not only about tropical
medicine but also about the challenges and huge advantages of opening a new facility in the
hospital. From the people I met I learnt about resilience, optimism and strength. As with any hospital
in the world there are further improvements that can be made – the road to the hospital could be
paved allowing use of an ambulance, further fully trained nurses could be appointed, medication
stocks could be better and the range of laboratory tests expanded. This all takes a great deal of
money and time however and the level of care currently provided by the compassionate and hard
working people of Masanga is an example to follow.
I would like to say thank you to Oz and the Masanga UK team for enabling me to be part of this
project and spend time in Masanga. Also to Dr Josien, Dr Alex, Dr Mark, Dr Jet, Bart, Anne-Marie,
Patrice, Emma, all of the CHOs, nurse aids, the Danish volunteers and all the other staff at Masanga
for their help and support with the opening of the Emergency Admissions Unit and for making my
stay in Masanga so enjoyable.