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Views & Reviews Personal View

Aid, aid everywhere but still not a drop in the sink

BMJ 2009; 338 doi: (Published 16 January 2009) Cite this as: BMJ 2009;338:a3136

Rapid Response:

Less than a Landcruiser.

We support many of the points Dr. Watson noted in her description of
the aid community in Sierra Leone (1) and also salute the good work that
the Welbodi Partnership is conducting at Ola During Children’s Hospital in
Freetown; however, there are also some encouraging results in Sierra Leone
from collaborative initiatives that have required relatively little
financial investment. The Society of International Surgeons (SIHS), in
collaboration with the local surgeons at Connaught Hospital in Freetown,
the Sierra Leone Ministry of Health and Sanitation (MOH), and the World
Health Organization (WHO) has had great success in addressing the issue of
emergency and essential surgical care, the so-called “neglected step-
child” of public health (2).

In February 2008 an assessment of most Sierra Leonean hospitals where
surgery is performed was conducted and the results were recently published
(3). However, instead of strictly being an academic exercise, SIHS through
its flagship program Surgeons OverSeas (SOS) began addressing the problems
the survey highlighted by providing salary incentives for Connaught
Hospital operating theatre staff and surgical ward nurses; facilitated two
3-day emergency surgery workshops; delivered a 40’ container of medical
supplies and equipment; and brought in six volunteers for technical
support. The total cost for all of these interventions was less than the
price of a single Landcruiser.

The results have been nothing less than spectacular. At Connaught
Hospital, major operative procedures are up by 51% for the year, while
overall hospital mortality is down by 1%. Just recently, the framework for
post-graduate training in surgery was established at Connaught Hospital
with morning handover meetings, consultant ward rounds, a journal club,
and morbidity and mortality conferences. Countrywide, forty-five medical
officers and nurses received training in emergency surgery, trauma care,
anesthesia, and emergency obstetrics, and each received a copy of the WHO
manual Surgical Care at the District Hospital and a CD with the Integrated
Management of Emergency and Essential Surgical Care toolkit – which are
now being used as an important reference text in many of the district

There are numerous problems in providing safe surgical care at
hospitals in Sierra Leone, including a lack of infrastructure and even
running water, however, the efforts of SIHS in close collaboration with
local surgeons, the MOH and WHO has improved staff morale, reduced
absenteeism, and led to the ability to conduct more emergency operations
for patients with no financial means.

We look to continue these collaborations and in the future expand
these programs to all the district hospitals and eventually health posts
in Sierra Leone. In the coming months, emergency surgery workshops will be
held on a regional basis in various district hospitals, salary incentives
will continue and hopefully be expanded, and additional supplies and
equipment will be brought in. We envision this SIHS strategy as a new
paradigm incorporating academic research with simultaneous programmatic
interventions that immediately begin addressing the needs of the subject

We feel that given the current global economic downturn it will be
important to continue providing assistance to the most vulnerable
populations, however, there is also a need to reevaluate the large budgets
of many current programs and collaborative efforts such as those conducted
by SIHS may be a more suitable alternative.


1.Watson, H, Aid, aid everywhere but still not a drop in the sink,
BMJ 2009; 338:a3136: 239.

2.Farmer PE, Kim JY, Surgery and Global Health: A View from Beyond
the OR, World J Surg, 2008 Apr; 32(4): 537-42.

3.Kingham TP, Kamara TB, Cherian MN, et al, Quantifying Surgical
Capacity in Sierra Leone: A guide for improving surgical care, Arch Surg.

Competing interests:
None declared

Competing interests: No competing interests

28 February 2009
Adam L. Kushner
Thaim B. Kamara, T. Peter Kingham
Society of International Humanitarian Surgeons, 303 E. 60th St, New York, NY 10022 USA