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Sierra Leone

Site visit by Professors Terence  Ryan and Christine Moffatt on behalf of WHO Working Group for Wound Healing and Lymphoedema, 30th November to 5th December, 2008.

This is a country with a population (July2008) 6,294,000. Once a British Colony and before that the centre of the slave trade.  It is a poor country which is still recovering from a civil war. The road network is poor and is made worse during the rainy season. About one third of the population is literate. 60% Muslim 10% Christian 30% other. The Health of the population is poor with a infant mortality rate 156/1000 and many major infectious diseases such as malaria, yellow fever, Lassa fever, schistosomiasis, onchocerciasis, and typhoid. The CIA gives a figure of 7% for HIV/AIDS but all sources met with on this visit gave much lower figures. More information on Sierra Leone (http://www.who.int/countries/sle/en/)

The Country is divided into 3 Provinces: North, South, East and the area of Freetown.  Sierra Leone is a very poor country. Agriculture employs more than half the population and a resulting consequence is harmful deforestation.
Sierra Leone was chosen as representing a very poor, post civil war country. Unhappily,  this is a model for many countries and it is important for our GIWLC working group to be familiar with such.  Our contact in Sierra Leone was Mr. Ibrahaim Vandi, a Dermatology officer trained by Professor Terence Ryan at a training school in Tanzania six years ago. He is a nurse who now is the only authority on the skin in a country of 6 million. The visit was facilitated by  WHO representative in Freetown. There was some delay while permission to visit the centre of the country was obtained. The roads were largely potholed, mud surface except for gradual replacement by tarmac. This adds to speed and extremely dangerous driving, creating, not infrequently, some of the wounds we had come to study.  Bo, a major city in the centre of the country,  offers very poor access. The 400 bedded hospital  is staffed by three surgeons  and the commonest operation is for perforated typhoid lesions of the intestine in children.. Another hospital we visited further north had one family practitioner with surgical skills.  Anesthesia was provided by untrained volunteers.

In Bo, we were fortunate to see almost by chance, a child with Buruli Ulcer. We also visited heads of other WHO programmes and pharmacies to assess costs and availability of wound healing materials.

The knowledge of wound healing and wound care practice is very poor. Despite this, the professionals we met were keen to learn and improve practice and much could be achieved by education programmes that make the optimum use of what is available locally. Simple protocols of wound hygiene , methods of managing wound infection using traditional and Western methods would contribute enormously. Over use of antibiotics and antiseptics is not only too expensive for many patients to afford, but may lead to increasing problems of drug resistance. Education should also address what can be achieved by teaching basic principles of bandaging and oedema reduction. There is great opportunity for joint university collaboration to support the development of wound care programmes and this could have an almost immediate impact on practice.

The conclusion of our report is that only the most acute life threatening conditions are seen by biomedical trained doctors and nurses.. All chronic illness or non-threatening illness is seen by Traditional Healers. Any major intervention must work with the Association of Traditional Healers.  We therefore visited Dr A. Turay,  the focal person for traditional and generic medicines in the Ministry of Health and Sanitation.  We have received  his agreement to the conclusions reached. These conclusions are that an initial programme should begin with instruction to Traditional Healers.  We should encourage good practices such as the use of Black Soap made by them which is antibacterial antiseptic and anti parasitic.  We should discourage bad practices such as scarification in lymphoedema.  Prof. Ryan has previously emphasized the importance of low technology in very poor countries. This is one example. It should be pointed out that there are private services and mission hospitals which we did not visit as we were focusing on the commonest routes into care.