Sierra Leone lies on the coast of West Africa with a population of 7.6 million people. Freetown sits on a coastal peninsula overlooking one of the world’s largest natural harbours. Long stretches of beaches lie beneath a colourful mountainous scenery of greenery, new constructions and corrugated sheeted shantytowns. It is a country of low income and poverty. Sixty percent of people live below the poverty line. In its recent history, the country has suffered civil war, Ebola and COVID crisis. This, combined with poverty, has weakened the healthcare system.
Since 2010, The British Society for Surgery of the Hand (BSSH) and ReSurge Africa (NGO) have collaborated to develop the first reconstruction unit in the country at the Holy Spirit Hospital, Makeni. This has included training two local plastic surgeons and a local physiotherapist. Because of civil war and Ebola over the last ten years there has been a shortage of trained doctors and therapists. In 2019, there were only seven qualified physiotherapists and one occupational therapist for the population. Through extensive work by Mr Kebbie and collaboration with Massanga Dk a Danish NGO, a Five year Physiotherapy BSc was started with a cohort of fifteen students to improve this. This year a further cohort of fifteen students will commence a Diploma in Physiotherapy.
In March 2019, I joined the ongoing BSSH project and assisted on a one-day multidisciplinary introductory course to medical staff, therapists, and nurses on improving the care of patients with hand trauma. This teaching visit highlighted that further specialised training was required for therapists in the assessment and treatment of the upper limb.
Aim of the Visit
The aim of our visit in October 2023 was to provide a collaborative two-day Hand Therapy Course. The course covered, anatomy, assessment, oedema management, scar management, principles of splinting, principles of exercise, management of the burnt hand and the deformed stiff hand. This was delivered to qualified physiotherapists and student physiotherapists.
UK Team Members
Mr Ian Grant Consultant Plastic and Reconstruction Surgeon
Mr Steve Hodgson Consultant Orthopaedic Surgeon
Miss Natalie Hope Orthopaedic Hand Surgery Fellow, Salford
Kathryn Pank Hand Therapist
Roberta Brincat Hand Therapist
Pascalle Smith Hand Therapist
Sierra Leone Team Members
Mr Ismaila Kebbie, Lead Physiotherapist, Ministry of Health and Sanitation and Head of Therapies, National Rehabilitation Centre. President Sierra Leone Physiotherapy Association
Mr Jesse Banhuah, Lead Physiotherapist, Connaught Hospital Freetown.
Mr Abu Amara, Physiotherapist-In-Charge, Tonkolili District College of Health Sciences. Lead physiotherapist, Sierra Leone China Friendship Hospital at Jui. Secretary, Sierra Leone Physiotherapy Association
Mr Balansama Janneh, Lead Physiotherapist, Holy Spirit Hospital, Makeni
Mr Ansu Kanja, Administration Physiotherapy, Tonkolili District College of Health Sciences.
Planning
Pre-visit planning consisted of a UK team WhatsApp group, two team Zoom meetings and email communications. The therapy team met face to face for a course workshop and a practical planning session. All team members received a travel check list produced by Mike Waldrum. Communication with the Sierra Leone therapy leads and UK therapy lead were facilitated by Kings College Partnership that resulted in a productive Zoom meeting with Mr Kebbie, Mr Amara and Mr Janneh. Pre course BAHT anatomy workbooks were provided to all participants through local leads three weeks prior to the visit.
Visit
We landed at the new airport in the capital Freetown, which was impressive and efficient. Outside, there was a familiar African heat, smell and humidity, with crowds of people offering to carry bags and touting SIM cards. From the airport, the Sea Bird ferry crossing was uncomfortable in the dark and rather choppy water, we arrived at our destination where we found a driver waiting for us to take us to our guest house. Our visit program consisted of two days of teaching at two locations, the government run Connaught Hospital, Freetown, and Tonkolili College of Health Sciences in Masanga.
Overall Impression:
The obvious need for surgical care in Sierra Leone is still apparent. The population is currently 8.4 million, and it grows at over 2% per year. Freetown is reported to have a population of over 2 million. The current GDP is about US$ 530 per person. There are only 2 plastic surgeons resident in the country. There are visiting NGOs such as Mercy Ships, Smile Train, and BSSH.
The obvious need for Reconstructive Surgery includes: Surgery for compound fractures of the upper and lower limbs.
Motorized rickshaws and motorbikes are crowded together on the streets of Freetown, jostling with mini-buses in varying states of repair, on poor roads. Many of the injuries are treated in rural communities with immobilization and the application of poultices by "traditional healers." Many of these injuries progress to develop osteomyelitis, and some result in amputation. An efficient, appropriately resourced service that provides a plastic surgeon with the necessary skills to carry out timely local flap reconstruction, and an orthopaedic surgeon to perform external fixation of fractures, would be a huge step forward. The first center would need to be in Freetown. If transport links and funding are secure, a second center could be in Makeni.
Acute burn care and delayed burn reconstruction: The country seems to pulse and teem with children. Cooking fire and cooking pot injuries appear common. In 2021, an oil tanker exploded in the Wellington suburb of Freetown, killing 90 and injuring many more. All the elements of burn care and burn injury avoidance could be built up. We saw children who would have benefited from early burn wound excision and grafting, better splinting and scar care, and appropriately timed surgery to deal with contractures of the upper and lower limb. The identification of funding to construct a National Burns Unit at Connaught Hospital is a significant achievement and a huge potential opportunity.
The Burns centre will need appropriate nursing, physio, and OT expertise. It should be able to manage IV resuscitation of major burns. I did not get the impression that there was a need for ventilation of burn patients. The centre will need locally resourced cost-effective supplies of dressings.
Connaught Hospital Freetown
The first course was held at Connaught Hospital in Freetown. Connaught Hospital is the principal referral hospital and training hospital of Sierra Leonne in Freetown.
During the planning stage, it was advised that the training would be suitable for qualified Physiotherapists. However, only two qualified Physiotherapists and a qualifying Physiotherapy student attended. The remaining attendees were qualified nurses from trauma and orthopaedic wards and a Junior doctor who was interested in learning about hands. Some of the attendees reported that their attendance was compulsory.
On arrival to Connaught Hospital, there was a delay of an about an hour in the start of the programme due to no keys being available for the teaching room. The teaching facilities were limited with no additional rooms for the three rotational workshops in the programme.
Tonkolili District College of Health Sciences, Masanga
The second venue, Tonkolili District College of Health Sciences, is three hours east of Freetown at Masanga. The college supports the training of Surgical 
Community Health Officers, nurses, and, most recently, physiotherapists. The Physiotherapy BSc program started in 2018. It was developed with support from national and international stakeholders and currently has its first graduating cohort in November 2023. This will greatly improve the number of qualified physiotherapists, of which there are currently only seven in the whole country.
The two-day course was delivered to the nineteen physiotherapists qualifying this year. College administration was efficient, and good teaching space was available. However, it is worth noting for future trips that there was no air conditioning, and the electricity supply was occasionally disrupted. Poor lighting shortened the end of our first day of teaching.
During the teaching at Masanga, we used Makeni as a base for our accommodation. We stayed at St Joseph’s School for the Hearing Impaired, which has a close relationship with Holy Spirit Hospital in Makeni. We were inspired by the school’s textile workshop that produces clothing, bags, and souvenirs for tourists.
Holy Spirit Hospital, Makeni
We briefly visited The Holy Spirit Hospital (HSH) in Makeni, which was established by Dr. Patrick Turay. Despite many atrocities in the last decade, such as Ebola, it has continued to develop and expand with the help of the Italian Diocese and sheer determination. The Holy Spirit Hospital now has seventy beds, an Outpatients Department, Radiology, Pharmacy, and two operating theaters. The physiotherapy department was destroyed by a fire in 2018, and now a new development with physiotherapy, pathology labs, and additional ward space for surgical visits has been built.
Evaluation
As a short, two-day course, the program was an introduction to specialist upper limb therapy. It encouraged education and empowered local therapy staff and students to provide a future cascade of learning and knowledge. This encourages a sustainable project for Sierra Leone to develop healthcare for the future.
This was excellent to see and embrace, as future projects can help the Sierra Leone team to expand and improve their knowledge and skills while also developing a good mentoring relationship between the UK and the Sierra Leone teams.
Cultural expectations of catering, time-keeping and physical teaching facilities challenged the UK team. Local administrative support and assistance helped to overcome this, but future visits must ensure that these issues are taken into consideration.
All teaching presentations, worksheets and course workbook were presented to the local clinical and therapy leads on a USB for future use, access, and reference.
Hand Therapy Course, Masanga Evaluation
Two-day Hand Therapy Course at the National Physiotherapy School, Masanga Hospital – first cohort of 16 students in their final month of a three-year program. The delegates were extremely enthusiastic and engaged by the teaching program, which included a large amount of hands-on opportunities.
As a short, two-day course, the program was an introduction to specialist upper limb therapy. It encouraged education and empowered local therapy staff and students to provide a future cascade of learning and knowledge. This encourages a sustainable project for Sierra Leone to develop healthcare for the future.
The UK team felt that following this visit, it was clear that all the participants were eager to learn and happy to improve their clinical skills in assessment and intervention. This was excellent to see and embrace, as future projects can help the Sierra Leone team to expand and improve their knowledge and skills while also developing a good mentoring relationship between the UK and the Sierra Leone teams. Cultural expectations of catering, time-keeping, and physical teaching facilities challenged the UK team. Local administrative support and assistance helped to overcome this, but future visits must ensure that these issues are taken into consideration.
Each day of our teaching was positively brimming with enthusiasm and a genuine keenness to learn. A pre and post-course quiz showed improvement in an average score of four marks, demonstrating improved knowledge. Course evaluation was very positive about the delivery and content of the course. All participants felt they had benefited from attending. Overall, 87% of attendees rated the course “Very Good” or “Excellent.”
Moving Forward
The visit was very beneficial and successful. It was good to provide the first specialist training for the first Physiotherapy BSc cohort. It was an opportunity to support and develop knowledge about upper limb conditions and management from the therapist’s perspective. We have built on previous connections and widened our network of local partnerships. In the future, there is scope to further enhance collaborative and sustainable education and working in Sierra Leone.
Positives
A good quality practical hand therapy course was delivered to very engaged students who provided excellent feedback. Abdulai and Eric have been established as Reconstructive, Burns, and Hand Surgeons at Connaught Hospital and are well-regarded by staff and trainees. Connaught Hospital is capable of supporting safe hand surgery visits in the future with good anaesthetic support. Holy Spirit Hospital remains a Catholic mission hospital capable of supporting further BSSH surgical team visits. The Burns Unit build is underway, which will include a dedicated Reconstructive, Burns, and Hand Surgery operating theatre. Surgeons are doing great work with many patients who would benefit from hand surgery, and clinical staff show a large appetite for hand surgery education.
Negatives
The global economic crisis is having a bigger impact in Sierra Leone than in the UK, with hospitals facing increased costs against static or falling income.
BSSH overall & therapist October 2023 Report.