From our correspondents-Rob Hughes currently in Sierra Leone
I hope you have enjoyed hearing from students from around the world. The last blog entry today is from Rob Hughes, a UK medical student who is currently on a final year elective placement in Sierra Leone. He reports from there—Rhona 
A maternity ward in Sierra Leone
“First they must pay… One hundred and seventy thousand Leones for the operation fee… twenty-five thousand for medicines… one gallon of diesel - thirteen thousand five hundred for that - and a litre of oil… after that we will call the doctor in.” [Nurse at Kambia District Hospital]
I cannot imagine just how scary childbirth must be… especially here in Sierra Leone where the maternal mortality ratio is amongst the highest in the world, (variously estimated to be between 1300 and 2000 maternal deaths per 100000 live births). But I can see that if complications arise - as they often do amongst a population of young mothers, with a high fertility rate, little birth spacing and limited antenatal care - the last thing you need is to have to come up with a sum of money more than most people’s monthly income before you get the caesarean section you need. It may not seem like a vast sum to those of us from the UK and other rich countries - around £35GBP in total ($70USD) - but here, now, where the harvest season is months away, and the only bank has only been open for a few months it is an undeniable barrier to access to care, especially for the poorest. At best it means delayed urgent treatment, and at worst it means mothers get abandoned at the hospital by families who either cannot pay, or are afraid of the bankrupting effect of ill health.
Such a distressing reality risks alienating and depressing us into inaction and despair; the determinants are so complex, and the inequity so stark. What can we do? Especially as an elective student, with a small, if growing, bank of knowledge, and minimal clinical experience or expertise?
I know many people have had similar elective experiences, and have also reached for that most basic guiding principle; ‘first do no harm’. But after you have carefully considered how to ensure that you do not overstep your clinical level, and are culturally aware and sensitive to your surroundings, what next? It seems woefully inadequate, but learning more about how and why such health inequity exists is surely a reasonable first step to beginning to try to challenge its determinants.
Obviously, ideally we should have at least a core understanding before we find ourselves in such a challenging elective environment. I - although far from an expert on any of these issues - really appreciate the grounding that I gained through intercalating in International Health at UCL’s Centre for International Health and Development (http://www.cihd.ich.ucl.ac.uk/). Given the limited availability of such courses (currently only offered only by UCL, Leeds, Bristol and Birmingham Medical Schools, although short courses are also offered at Leicester, Southampton and Swansea) surely there is a place for more pre-elective preparation than a talk on risk-assessment, travel vaccinations and professional indemnity that seems to be the norm at most British medical schools? If we are - rightly I think - to travel the world on our electives, we should learn something about the health system we are to work in.
I think we should all know something about the role of various members of the ‘development industry’ who spend aid money driving fleets of white land cruisers and debating how healthcare user fees should be applied by developing country governments, and understand a bit of the dynamics of the global brain drain of health professionals that leaves Sierra Leone with a scattering of doctors while in the UK and US medics sometimes fight over vacancies. Even if we never leave our home country or health system, in today’s globalised world these issues are relevant to us all. Robert Hughes