Saturday, July 3, 2010


This is a post I initiated in March but never finished. Now that I've gone again, I realized I need to get it out. Hope you enjoy.

I just found the coolest flickr photostream about Sierra Leone from a guy named Adam Cohn. This is more what it looks like than my very amateurish photographic attempts. I hope this link works because its captivating. Unfortunately, my camera battery died out here so I have very few photos from this leg of the trip.

For the last 6 months we've been getting reports about the excellent work being done out in Bo where three of 2009's trainees live. One of them, Musa Mansaray, is the Director of Rehab at the Bo Rehabilitation Center (BRC). Bo is Sierra Leone's second city, located about a 3-5 hour drive east and a little south of Freetown. Fortunately, the Italian government has recently built a paved road, making travel far, far easier.

Madonna is huge here. Or, at least these huge stickers of her are all over their taxis and buses.

This part of the country was very hard hit during their horrible civil war. The reason so much conflict happened here is that this is one part of Sierra Leone where Diamond mining is prevalent. Without dwelling too much on the specifics, the people of Bo suffered immeasurably during the war, leaving many with amputations and amplifying endemic polio. Therefore, the need for wheelchair services is as great in Bo as anywhere in the world.

Fortunately, the people of Bo (and the rest of Sierra Leone) have been steadfastly supported by Handicap International, one of the most effective organizations for helping people with disabilities in the world. One focus for HI in Sierra Leone has been in support of the Rehabilitative Services, strengthening and supporting the clinical programs country wide. As in Liberia, many of the clinicians here are 'mid-level therapists' or former nurses and social workers trained by European HI staff for up to 2 years. There are likely 3 or 4 Physical or Occupational Therapists in the entire country. Musa Mansaray, the director of the BRC is one of them.

We were able to work with Musa and his staff to gain an initial feel for their skill level in context of the wheelchair distribution process. So far, so good. Coming from the US and knowing what we have, I must say I was impressed by the vibe and hard work going on in their rehab center. The heat and conditions aside, it felt like any rehab gym in the states. People where working hard to improve their motor function. They have the basics and use them to get the job done as best they know how.

We assessed one of the wheelchair users, a 16 year-old refugee from Liberia. When I first viewed him in his chair, I felt something was very wrong. Either he had grown 5 inches in the last year since he had the chair, or his chair did not fit him. If a chair is too small for a user, their weight rests almost completely on their sitting bones, placing them at risk for a pressure ulcer. That said, the seat length, depth and backrest were appropriate and the chair was in good order. He uses it every day as his primary source of mobility.

As I assessed the fit of the boy in the chair, I realized that in addition to the infection they were treating he has all the symptoms and movement patterns of Duchenne's muscular dystrophy (undiagnosed). He lives in a refugee camp on the outskirts of town and had to travel several miles across a bumpy trail to get to school. With great relief, I realized the staff had trained the family how to adjust the footrests of the chair and raise the footrests so they wouldn't high-center the chair. This tells me the clinicians had measured and fit the chair appropriately and the technicians had built it correctly. Most importantly, the family had received correct instructions for adjusting and maintaining the chair. This is a very good initial case study for the BRC!

It is important to note that I was aware of my own bias coming into the situation. It would be easy to believe that, "Yes! they are doing it correctly and I'm so very happy to have gone!" However, Ike and I realized that catching a glimpse of one small part of the rehab center's week and transposing that across the entire wheelchair program in Sierra Leone would be dangerous. We had many, many long discussions about the need for an objective evaluation of the program. The need to truly analyze the skills of the clinicians and technicians we trained and the people they have since trained.

More to come about the Mobility Sierra Leone workshop soon.

Sunday, April 25, 2010


I got to go on a really great run to the top of a little mountain overlooking the city. Everyone was saying there was a very unusual haze for this time of year. Usually you can see forever out into the sea. (Double click to see detail)

One of Last year's biggest challenges was accurate measurement of the patient's body for the wheelchair. The chairs we provide are built to fit the user's hips, thigh length and lower leg height. An accurate fit might make all the difference in the wheelchair user's success or failure with the chair. We found that measurement continues to be a challenge for our clinicians.

Through a unique twist, we found that Motivation held a training at the Rehab Center the two weeks before our arrival. Nicky Seymour was a Motivation trainer who gave us excellent feedback on her training and the general situation there in Freetown. We were able to evaluate Emily and Cecil as they assessed a patient for a new wheelchair.

Here she is with her current chair

As a Physical Therapist, I can say that its always difficult to have another Clinician around to critique your work. There is an extra pressure that can make you overlook the obvious. Having two people observe and critique your work is twice as bad. That said, Emily and Cecil did very well with their patient evaluation. We had to review measurement again and hopefully practice will make perfect.

One of the issues that came out of Nicky's observation is that there had been some chairs in Freetown that were issued without proper fit. This dangerous situation came about when one of the government officials ordered the staff at the Rehab Center to build a bunch of chairs and hand them out without fitting. The politics of Sierra Leon are famously rough handed and I can't blame the staff for following orders. Fortunately, we are working with them to disallow this in the future.


One of the most exciting things about the LDS Humanitarian Service and LDS Charities is the intelligent ways in which they pursue their mission. The Wheelchair Initiative has been fortunate to partner with Motivation UK, gaining much from their long experience in providing very high quality, low cost wheelchairs AND training clinicians and technicians for prescription wheelchair service. The Worldmade philosophy and program is explained on their website and some background is in the blog I wrote last year. My respect for them continues to grow as I see the progressive way they pursue their goals. Fairly brilliant approach and execution.

One of the Hallmarks of the Motivation approach is to train Clinicians and Technicians in a prescription wheelchair service. This approach magnifies the clinical and technical skills of wheelchair providers in areas that need it most. Motivation has several levels of training and LDS Humanitarian services has worked to incorporate their training system. Obviously with an effort and need this broad, there are many diverse ways of approaching the problem.

Last year we were able to go to Liberia, where we taught teams from Liberia and Sierra Leon for the Worldmade Fit for Life program. The goal was to 'train the trainers'. The program has been largely successful in that the teams from both countries were able to extend the training by relaying their knowledge to other clinicians and technicians.

This year we wanted to follow up with the teams from Sierra Leon and evaluate their implementation. Isaac Ferguson had been to Freetown to implement a Neonatal Resuscitation Training in the fall and made a surprising discovery that the technicians from Bo had formed their own Wheelchair Production site. We were keen on visiting this site to evaluate the quality and efficacy of their program. We were also very interested in evaluating the performance of the clinicians in Freetown and Bo.

Ike Ferguson and I were sent to Sierra Leon for the first leg of our trip. We flew from SLC to JFK and then to Accra, Ghana and finally to Sierra Leon. Arriving in any 3rd world country is always a shock and this was no different. The airport is across a big bay and there are several ways to get across. On the way over, we took the 'speed boat', which was like a floating yellow sauna.

Its just amazing to leave Utah on a 60 degree spring day in March, travel across the Atlantic and end up in 95 degree heat with 100% humidity. Getting to the boat involved driving in a small bus down a half mile of dirt roads to the shore, where it was blissfully cool. Then we had to put on the lifejackets and get into the sauna.

Of course, there were more temperate alternatives:

Freetown is an amazing mountainside city by the sea that was founded by freed slaves from returning America and England. The English used it as a returning point for Africans liberated from slave ships in the 1800's and the Colonial influences are found throughout.

We found the Sierra Leonian Navy.

And the famous Cotton Tree, where freed slaves prayed under and Christened Freetown

The most exciting part of arriving in Freetown was the 15 minute drive to the Mission Offices. Aside from being in such a cool and very foreign feeling place, we saw over 11 Worldmade Wheelchairs!

This was an encouraging sign as we were hoping to be able to assess someone who previously received a chair and evaluate the appropriateness of their fit.