Going Home

I am writing this just after midnight on the plane from Freetown to Heathrow. I have always found that flying is like being in emotional suspended animation. Any excitement, or trepidation, or sadness, there might have been in the departures hall, switches off with the bump of the wheels leaving the runway. In less than 6 hours, normal life will be resumed with the sound of seatbelts being released and overhead lockers being opened, but for now, I am in a different place –  35,000ft above somewhere in North West Africa, feeling calm and clear-headed.

When I saw my boss last Friday, I told him that I had just had  a great two months. He had just presented me with a big hand-woven blanket from his home village, embroidered with my name and thanks from him and his family. I’m not exactly sure why my experience has been so good, but it has worked for me on lot of different levels. Professionally, it has been interesting and challenging; socially it has been fun; and Laszlo’s obvious enjoyment and fearless willingness to get involved during his visit has been great.

One of the things that has surprised me most about my time here has been the way it has brought back stories about things that happened to me in my twenties, when I was a VSO in Uganda. Quite a few people have asked me about those days (including Ugandan VSO’s who are too young to remember them)  and I have talked about the things that happened, including my experiences from the war there.

Many of the people I have met in Sierra Leone have experienced horrors in their lives that I hope I will never even dream of. Some of them will tell their stories freely, but others seem to be struggling to make sense of them. Even my most difficult experiences, of course, are absolutely nothing in comparison, but being here has made me realise how important it is to find a way to tell our stories – all the fragmented bits that add up to a life.

I don’t feel at all pessimistic about what I have seen and experienced. In fact my strongest impression is nothing to do with conflict, trauma or poverty, but about meeting people with a fundamental self-belief that would be the envy of many of us neurotic Brits (speaking for myself here, you understand). A friend of mine once gave me a fridge magnet that said – “Sing as though no one is listening; dance as though no one is watching; live as though heaven is on earth”. It has been my privilege to live and work for a while alongside people who really seem to know how to do that. I know I will never be able to dance like a Sierra Leonian (and don’t worry, I won’t even try) but I do sort of hope a bit of that attitude might have rubbed off.

So that's it from the Freetown Blog, but please forgive me one last self-indulgence. One of the tasks that I would normally have been doing over the past two weeks is writing Christmas cards. It is a bit late for that now, so please accept this home-made one with my very best wishes for the festive season and the coming year.

A festive Freetown surprise

I was lying on my bed under the mosquito net in the dark, sometime after 10pm. It was a very warm night (so no surpise there) and I was glad of the slight breeze blowing in through the open windows. Suddenly a sound started up outside that was as surprising as it was familiar.

Here in Freetown, I am quite used to late night West African music, but  a brass band playing "See Amid the Winter Snow"? It turned out that it was the Freetown Police Band. I was brought up in a small village in Devon and every Christmas the village band would  travel the parish playing carols at the outlying farms. The band often received refreshment at the places they visited. As the evening wore on, and more hospitality was received, the carol playing would increasingly become a triumph of enthusiasm over technique. As you can hear from the attached clip (which I recorded on my ipod recorder), I suspect the same tradition of hospitality operates here.

The Boat Pushing and Other Adventures

We are now back in Freetown after 8 days of travelling down the coast and up-country. We set off last Wednesday with only a vague plan, deciding to travel light without much gear and hope for the best. And the best was, pretty much, what we got.

Our first stop was River Number 2 Beach. Before we left Freetown, I was unsure how easy it would be to get places to stay, but as it happened we were the only visitors there (and that continued to be our experience for the whole week). That evening on the beach we had a good chat with the only other person on the beach - a Bristolian, who first arrived 10 years ago on a government engineering project, and seems have all he wants for a happy life in his beachside house, with his Sierra Leonian wife and the gin bottle in the pocket of his shorts. We could certainly agree with him that as far as the setting is concerned, River Number 2 is hard to fault.

The next morning we crossed the river mouth by boat and walked three miles down the beach to Tokeh Village. Tokeh Beach was the site of the filming for the original Bounty Bar advert in the 1970's and you can see why the chose it -the sand is so white and so soft that it is more like walking on snow than on sand - it even squeaks like powder snow. Tokeh village is a fishing village and when we arrived they were just selling off the night's catch of lobster, makerel and small barracuda.

From Tokeh Beach got some transport a few miles south to Bureh Beach, where we were hoping to find some beach huts to stay in. In the event, we were over optimistic. However, we did find local lads who, from somewhere, found us a tent, which they hired to us, cooked us a supper of fantastic grilled fish, lit us a bonfire, and sat round the fire with us singing Sherbro songs and comparing the quality local gin and Hungarian Brandy (the the words of the songs, we later found out, would be enough to make a rugby team blush!)

 

 

One of the many remarkable things about the Freetown Penninsula is  the way the sand colour changes in just a few miles. The sand at Bureh Beach is a deep golden colour which almost looked like it was glowing in the early morning light.

We found that as we travelled down the coast, we were continually meeting up with the brothers and cousins of people we had previously been with and began to suspect that word was travelling ahead of us  that there were two white guys on the way in need of assistance (mobile phones are a wonderful invention). From Bureh Beach, we were offered a boat trip across to the Banana Islands (which was our destination anyway). The starting price was $100, but we eventually settled on $30, and it seemed everyone was happy. And so it was that we arrived at the Islands, which are just three miles off shore from the Peninsula.

 

 In the early 19th Century, the Banana Islands were used as a base by the Royal Navy in an effort to stop the slave trade, which was continuing at that time despite legislation in the UK to abolish it. The islands are now a place of complete quiet and peace, with only about 1000 inhabitants, but the traces of their military past are there to see, including a number of half buried cannons, one of which clearly shows a foundry mark of 1813.

We stayed 2 nights on the Islands and it was one of the most relaxing places I have ever visited. Before we left Freetown, I picked up a novel that was lying around in the house in anticipation of getting a bit of time to read on the beach. It was Jane Austen's 'Mansfield Park', and you might think that such a novel of 19th Century England would have little connection with the Banana Islands. However, as I read it, I discovered that it was written between the years of 1811 and 1813 - exactly the years when the Royal Navy was here on the Islands. One of the characters in the novel is a naval captain (and Jane Austen herself had two brothers in the navy), so it is not impossible that she had a fair awareness of what was going on here. One of the significant aspects of the first part of the novel is the prolonged absence of Sir Thomas Bertram, who travels to  Antigua to  attend to financial difficulties on his estate - problems  we can assume were probably caused by the loss of the supply of cheap labour resulting from the efforts of the Navy here and elsewhere along the West African coast. It all brought home to me just how closely tied the history of this part of the world is to the great events of the 18th and 19th Century in the UK and Europe. The same events have had repercussions down the generations here and many argue they were a significant factor in the events that recently tore Sierra Leone apart.

During our second day on the islands, we were shown a boat, which had just been completed after 9 months of manual labour and was due to be launched the following day. The site where the boat was built was in the middle of Dublin Village, and getting it to the water involved pushing it several hundred metres down to the beach. We were invited to the ceremony, and duly turned up next morning at the appointed hour. The ceremony began with us all being asked to gather round the boat and recite the Apostles' Creed; then sing Now Thank We All Our God ("first verse only"); then The Doxology; then we had the tossing of Kola Nuts to seek the blessing of the ancestors; the sprinkling of palm oil and palm wine; the throwing of food  into the boat (which was eagerly grabbed by the children). Then, amid much chanting and general hilarity, the Boat Pushing began, and we joined in.

 

When the boat eventually got in to the water, it floated with perfect balance, but that was not enough to stop us being alarmed when it was decided that the maiden voyage of the boat should be the one that took us back to the mainland. If I look nervous in the photo below, and as if I have just grabbed one of the only two available life jackets, it's because I was, and I did.

 

Our arrival point back on the mainland was Kent Beach, at the slave wharf where John Prescott madea speech on the 200th Anniversary of the abolition of slavery ("from such an idyllic place, so vile a trade").  It was yet another stunning place that we had to tear ourselves away from after only one night to travel up-country.

The day we left Kent, we travelled up to Mile 91 to meet with my VSO friend Jayne, and the following day, travelled on north on a dusty 8 hour round trip to visit the Bumbuna Falls. As you can see from the photo below, the road, particularly the last bit, was not all easy going.

When we parked the car, we couldn't actually see the Falls, but could hear a rumbling, more like a jet plane accelerating down a runway than a waterfall, and when we got down the path in front of the Falls, the sound was almost too deep to be audible - more like being thumped on the chest by the force of the water. The driver of the vehicle we hired to get there had lived in Sierra Leone all his life without seeing the Falls and was as mesmerised as we were.

By the end of our trip we were pretty comprehensively dust covered. The sort of dust which, I fear, will not get extracted from every orifice until long after I get back to Cardiff!.

And so, it's back to  noisy, dirty old Freetown. I arrived back this afternoon, to a phone message from my boss, saying he has a lot of things he needs to finish by Friday and really needs my help. I find that I am really pleased about that - to be busy and involved right up until my last day is how I would want it. So tomorrow, Laszlo will be off to negotiate Freetown on his own. Hopefully, we will meet up again tomorrow evening..

Institute for Healthcare Improvement

Over the past 20 years, I have been involved in a lot of different health service quality improvement projects and my experience has generally been that they promise more than they offer. It was therefore surprising for me to find that the IHI approach to quality improvement that is guiding the 1000 Lives patient Safety Campaign in Wales has sustained my enthusiasm for so long.

My interest has continued since I have been here, as it soon became clear to me that the challenges of connecting front line clinical staff with other organisational levels, and making change and improvement sustainable, are faced here just as much as they are anywhere else (as my VSO friend and erstwhile Matron from the Royal London puts it: " the thing is Tim, it's the same old shit, just a very different scale!")

Last month, I made contact with IHI and discovered that they have been working on a large scale project for child health improvement in Ghana. They have been supporting the testing of small scale change ideas to discover which ones result in measurable improvement and are now spreading and scaling up successful ideas. This is probably even more radical in a developing country context than in the UK, as donor-led development projects tend to be very long on high level strategy and very short on how to actually go about sustainable implementation.

Over the past two weeks, it has been great  to put Dr Kargbo, the Director of Reproductive and Child Health in Sierra Leone, into direct contact with Nana Twum-Danso, who is leading the IHI project in Ghana. I have been talking to Dr Kargbo about the IHI approach for a while and he was interested to find out more.  It now sounds like the IHI is very positive about the potential to support progress in Sierra Leone - an opportunity to work on health service improvement across the full spectrum from the very top of the UN Development Index to the very bottom. It may be that it takes a while before anything comes of it, if it ever does, but if I have done anything to help it come about, I will be well pleased.

First day of the holiday

As it happened, the rendezvous at the airport went without a hitch. After an evening beer with the Kenyan VSO's,  I had a comfortable and low stress helipcopter trip over to the aiport  with windows, seats and even ear protectors. Laszlo's flight was more or less on time and I booked a room at the airport hotel (not so grand) so all in all the whole thing was pretty straightforward.

Yesterday morning we had a leisurely breakfast before strolling down to the water taxi jetty at the beach. The sailing schedules depend on flight arrivals so we weren't exactly what time we would leave, but the beach makes a pretty good waiting area. Soon after we got there, some local lads identified Laszlo as in need of some intensive football coaching (they obviously spotted that I was a lost cause in that department). So Laszlo spent his first morning in Sierra Leone engaged in a vigorous game of footie.

When the boat arrived, a team pic was requested with 'Laz', and I was happy to oblige.

  

Getting to the airport

Freetown has the third largest natural harbour in the World. The city itself is on one side of the harbour, while the airport is way over on the other (think Penarth to Western Super Mare). This is not great if you need to get to the airport as the transport options are not very inspiring - rusty old car ferry, rusty old helicopter, or small water taxi  (a bit hairy if it is dark or rough). However, things are looking up - a new helicopter has recently come into service, which has glass in the windows and individual seats; and a new foot passenger ferry started three days ago.

This is all of particular interest to me today, as I need to get over to the airport tonight to meet Laszlo. I have ruled out the car ferry, as even getting to the terminal at the Freetown end can take hours. The passenger ferry fare is half the cost of the helicopter, so about an hour ago, I phoned the ferry office to find out about their schedule and booking arrangements. They just said I should turn up around 2300 tonight and they should be leaving around 2330. This would probably be fine, but it is such a new service that it is difficult to tell whether it is reliable and  I found myself considering a worst case scenario which involved me stuck at midnight in the City Centre, and Laszlo at Lungi airport, facing the scrum in Arrivals on his own. So I have decided to go by helicopter, which leaves from much nearer to where I live. I just hope that I get the one with the windows, and the seats.

Tying things up at work

It's my last few days at work now, and I'm trying to finish things off and spend time talking to others about their plans for next year. One of the things that keeps surprising me is when I find people with great skills who just need a bit of support to help focus their efforts. There is one man, Dennis, in the department who is Rwandan and initially came to Sierra Leone to help with monitoring elections. He later had to leave SL because of the war, but subsequently had to leave Rwanda for the same reason and returned here. He has been working in the Ministry for a while, though without a salaried contract.

Dennis is fantastic on Microsoft Access and Excel. By sitting down with him and talking about the sort of questions we need the staff headcount database to answer, he is well able (far more able than me) to generate the reports required.Some of the answers are shocking, but they really help the Ministry to state its case to the Government and to donors.

One of the issues we have picked up is that around 50% of the newly qualified Enrolled nurses appointed this year did not take up their posts. It is not difficult to see why when you understand that transport to get to their base could easily be $10, and basic accommodation could be $50 per month, and compare that with the salary scales:

Grade	Monthly salary
14	$  359	«Consultant
13	$  276
12	$  195	«Medical Specialist
11	$  151
10	$  90
9	$  69	«Medical Officer
8	$  52
7	$  40	«Nursing Sister
6	$  28
5	$  22	«SRN
4	$ 18	«SEN
3	$  16
2	$  14
1	$  12	«Nursing Aide

The only way anyone is able to keep functioning at work at all is through making informal charges for basic services. But with general poverty rates as high as they are, that means that many people simply cannot afford to access basic health services at all.

So you see what I mean about the scale of the challenges here.When you work with people who have seen services decline through the years of conflict, and are still struggling to get things moving back in the right direction, you can only admire the tenacity that keeps them going.I'm starting to wonder how all this might make me view the problems and constraints of the Health Service in Wales on my return...