Segbwema, Kailahun District, Sierra Leone
Monday June 12, 2017—Dispatch 3

By Randy Thomas Jones

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Today I’ll return to the story about how contact tracing, maps and public health all connect the dots that form an arrow pointing us to come here to the verdant and vibrant atmosphere of West Africa, to gather people with Android phones, to find motorcycles with their drivers, and make maps of places that can literally be “off the map.” In many cases, being unrecognized means that voices from the hinterland are not noticed, and this is the first step to helping people say to the administrative systems of the modern world, “We are here.” In a way, an analogy could be that if one called for an ambulance in the modern world, one would expect to be asked, “Where are you?” And given an answer, to expect them to arrive. In low-income settings, sometimes the difference between being known and unknown is a difference between life and death.

Yesterday I was discussing the need for mapping in Sierra Leone, and how the lack of accurate maps and gazetteers hampered the response to Ebola in 2014. In Nigeria, on the other hand, extremely aggressive contact tracing did effectively stop the outbreak before it became an epidemic. Nigeria had the infrastructure available to a wealthier state that made it possible to ask the key question of where patients were from and receive an unambiguous answer. Sierra Leone has been declared Ebola-free for 18 months now, but Sierra Leone is still considered “At Risk,” because the virus is in the environment and could again transfer to the human population.

One of the things that becomes apparent after some consideration is that the creation of maps and an unambiguous gazetteer (which lists not only village names, but the association with higher administrative districts) is much better done before a crisis hits. And of course, registrars at clinics and hospitals have to understand why it is necessary to use them, and be insistent on a full answer when asking, “Where are you from,” or, as sometimes is the case when someone brings in a friend or relative, “Where is this person from?”

Dr. Monk is developing his portfolio to focus on both UK-based medical practice and Global Health for Alternative Certification in Core Medical Competence, enabling him to tailor his studies to his interest area of epidemiology, infectious diseases and microbiology. He’s a congenial ball of fire when he invites us to the local bar in Segbwema Thursday night, and he and Ivan happily trade stories, both of them enjoying the meeting of minds with similar obsessions. Ivan considers him a great resource as a friend to the project—the more typical situation is that doctors don’t pay that much attention to public health (again, that old bias of the consequentialists). Doctors, and quite rightly, tend to be Kantians.

Friday morning we walk up the hill from our guesthouse to meet Monk. Or, more precisely, he arrives at 8:00 in the morning with a typical British enthusiasm and a warm invitation to the canteen at the Nixon Memorial. A breakfast that is unusual, for the Western palate, composed of fish and rice, but I do remember the “Egg and Bread” from my visit to Ghana last year, and determine to track that down whenever possible!

After breakfast, we take an extensive tour with Ed through the hospital find out that the Nixon Memorial Hospital has surprisingly good practices for registration. “Daddy” is the registrar at the outpatient desk, and takes great pride in his system for keeping track of patients. To the inexperienced eye, it looks like a haberdashery of file cards in randomly placed boxes. In fact, Daddy passes every inquiry regarding how individual patients’ records can be traced through his system. He has aspirations, and borrows a computer to practice his Excel at every opportunity from the hospital lab. Similarly, Betty, who manages the intakes on the wards, confidently pulls out scrolls of old records and points to one. “That would be in that one,” she says. Ivan rates them in the top 10% of facilities he has seen in low-income countries (the term he prefers to the usual terms “undeveloped / underdeveloped / developing”).

What started out seeming to be a quirky interest in records turns out to be only the “responsibility of care.” I’m getting enthusiastic about records myself at this point, and there is a certain kind of devotion to the practice that is as important as remembering to feed all of your children, and not leave one hungry.

Leveraging the goodwill that Monk has built, we make some very casual inquiries as to the possibility and interest for adding any columns to the intake books. Currently, the disambiguation of towns with the same name is done informally, depending on Betty and Daddy’s admittedly formidable memories. There are complications to this; one of the master books is a federal record that has a specified format that doesn’t meet standards for current best practice. But the answer is a tentative and provisional, “Yes, possibly.”