We began our day at the World Hope office, excited after receiving the news that our social IRB had been approved for fieldwork. Shortly after arrival, we headed out to 3 clinics, one of which was in a rural town about an hour from WHI. At the Tambiama Community Health Unit (CHU) we were introduced to Jarialu A. Fornau, an assistant nurse. She worked at this particular clinic for 7 months and was knowledgeable about the care that newborns and mothers received after giving birth. They are taken to the postnatal room, examined for 24 hours, and are encouraged to not have children frequently. The clinic handles up to 20 births per month, with major complications only being twin births. Typically they are referred to government hospitals, but distance and transportation pose a major issue. In general situations of high fevers and serious headaches, penicillin is prescribed. She emphasized that it is rare that patients to report bone pain, and that she had not seen sickle cell disease in her time working at Tambiama. She detailed that the clinic does not regularly hold any vaccine days. When asked about sickle cell, she explained that people do complain of serious bone pain and that they will not have the strength to carry anything with weight. However, that sickle cell is not diagnosed. Unfortunately, when testing for malaria, most patients are positive. We thanked her for her time and knowledge and left to go to the next clinic.
We then ventured to the Panlap Community Health Center (CHC) and met with Lansana Turay, a Community Health Officer. When comparing CHCs and CHUs, CHCs tend to be better equipped with materials and vaccines. Turay explained that HIV, malaria, and COVID tests are most commonly administered. Reagent tests are also utilized to test for protein and glucose in urine. Typically 10-20 patients are seen a day, and despite having more resources than a CHU, they still struggle with a lack of equipment, drugs, blood transfusions, and a lab of their own. They give a multitude of referrals to local government hospitals if cases become too severe, which usually includes advanced pneumonia, anemia, and seizures. Turay believed that sickle cell was a disease that affects the bone marrow. He understood it was inherited from parents and told us that the typical age range was 5-15 years, emphasizing that very few infants were ever tested or reported for sickle cell disease. When asked about vaccine days, he made no mention of routine days but explained that the clinic does administer vaccines to children under 5 years, including polio and hepatitis. Later we had the chance to look at some well-child visits and vaccine log books, which was extremely helpful in gaining a better understanding of how the clinic operates.
Soon after we left we headed to the New Hope Hospital where we met with another CHO. This was the first private hospital we had had the chance to visit and we were quick to recognize the differences in operations between public, government-funded facilities to private, donor-funded hospitals. The equipment and facilities were in better condition, the building itself was more cleanly, and there was quick access to lab test results. Dennis, the CHO we interviewed, told us that lab test results could be received in a matter of 15 minutes. Additionally, not many births occur at the clinic. Surgeries were the main focus of the hospital. There were two surgeons who were able to perform vasectomies, hernias, and cesarean sections, among others. For infections, antibiotics and prophylaxis were mentioned. Regarding bone pain, we were told that bone pain is treated with a variety of antibiotics and vitamins, excluding iron and prescribing folic acid. Despite sickle cell disease not being tested for at the clinic, they do diagnose based on the signs and symptoms of patients. Occasionally, Dennis said they do have situations where patients will go unconscious after a pain crisis, usually in the age range of 18-25 years. He was one of the few we have met that understood that sickle cell disease is caused by the sickle shape of red blood cells and that anemia was a common indicator. He described pale palms and eyes, as well as seeing low HB on blood test results. Dennis also mentioned that people do prefer private over government-funded hospitals for birth, due to increased comfort and care. Interestingly enough, we were told that many of the staff’s relatives will receive treatment at the private hospital, therefore lowering the cost. This was an indicator of the money barrier present for private care; while private hospitals might have better resources and level of comfort unless you have the money to pay, it is not a feasible option.
In the afternoon, Sulaiman took us to four pharmacies and a private health clinic. Out of the four pharmacies, only three of them spoke to us. One of them did not know what sickle cell disease was. They were more willing to talk to us this time as compared to yesterday. The pharmacists from all three locations that spoke with us said they have heard of sickle cell disease but only the second pharmacy had treated people for it. The first pharmacy was MJ Chainwork Drug Store and he said that the people who come in with bone pain were typically around age 14 to 16. They would either be given Compain (7000 leone for 10 tablets) or Iramax 425 (5000 for 1 cap). We also found out that they get their supplies from Freetown but can buy them wholesale in Makeni.
The second pharmacy was Emmah & Marion ENT and the pharmacist believed that sickle cell disease was because of holes in the bone, which causes the pain. People with sickle cell disease have gone to the pharmacy for treatment and their main symptoms were bone pain and heavy fever. They would offer three types of medicine for patients with these symptoms. One of them was BCO syrup for short term relief (30,000 leone) but since it is more expensive, not everyone can afford it. The second medicine was rasthanol, a respiratory asthma combination treatment (3,000 leones) and the last one was calcium tablets (10,000). Another interesting fact we found out was more patients experience bone pain during the rainy season.
The third pharmacy we visited was called Kadijatu Abass Enterprise. The pharmacist we spoke to did have a basic understanding of what sickle cell disease was, and he said his pharmacy has received a few clients with sickle cell and complaining of bone pain. He stated that his understanding of the disease was dry bone marrow, but he did not mention any information regarding red blood cells in the sickle shape. For their clients with bone pain, this pharmacy offers folic acid (1,000 leone per 10 tablets), calcium tablets (10,000 for tablets and 25,000 for syrup), as well as a BCO (Vitamin B) injection, which is the more expensive option. He emphasized that none of his drugs were free, as his business purchases their supply of drugs directly from Freetown, but they are generally affordable to the public. Our interactions with pharmacies were very informational, and our team has come to an understanding that different pharmacies sell a great variety of drugs for bone pain, some we are familiar with and some we had not heard of, even though there is a general lack of thorough understanding of sickle cell disease.
Sulaiman also got us into contact with another clinic right outside the city called Oprah Community Health Post. This clinic was small with only one doctor, eight nurses, and a community health officer. We talked to Ierissa Koma, the community health officer. We asked him about his experience with sickle cell patients and he said he has had two in the past year, which is generally the same amount we’ve heard from other clinics. These patients come when their symptoms flare up during the rainy season, which we have heard from other clinics and pharmacists as well. Their clinic doesn’t have any tools to diagnose patients, so they diagnosed them based on their symptoms which consisted of headache, fever, dizziness, and of course, bone pain. They record their medical history, which is how long the patient has had sickle cell symptoms and how they have been treated in the past. The past treatment consisted of B complex administration through an IV and metamizole, which is a painkiller. B complex has been proven to help sickle cell patients because many patients suffer from vitamin B12 deficiency. Since they have no way to diagnose besides the symptoms, we asked them if they would be interested in our device and they enthusiastically said yes.
