Teach to leave.
Protocols that survive your departure.

00 Pre-work before arrival

Do not arrive cold. The most common failure mode for visiting clinicians is landing in Makeni without having done the preparation that would let them move at the right pace from day one. Start these eight tasks now.

01 What to unlearn

Training in high-resource settings creates habits that are counterproductive in Bombali. The following four assumptions will undermine your effectiveness if you carry them in unchallenged.

02 The clinical reality — leading causes of death

Maternal mortality in Bombali District stands at 443 per 100,000 live births (MOHS 2022). The national target is under 70 by 2030. The gap between those two numbers is the work.

Leading causes of maternal death

Under-5 causes of death

03 The 5 highest-impact interventions

Three weeks is not enough time to fix a health system. It is enough time to embed five specific skills that will save lives for years after your departure. Prioritize ruthlessly.

04 Triage: ETAT protocol

ETAT — Emergency Triage, Assessment and Treatment — is the WHO-validated triage framework adapted for low-resource settings. Its core principle: identify children who will die in the next hour if not treated immediately. This is not a doctor's task. It can and must be done by the first person a family sees when they arrive.

The four ETAT zones

The ABCD assessment

The ETAT assessment looks for four categories of danger sign. Any single sign from any category places the child in the Emergency zone:

The system failure ETAT addresses is not a lack of clinical skill — it is the "dying child in the waiting room" scenario where a child with ABCD signs is placed in the general queue while stable adults are seen ahead of them. Training all intake staff — including guards, registration clerks, and community health volunteers — to perform this rapid check eliminates that failure.

05 Maternal emergencies: PPH management

Postpartum hemorrhage accounts for 33% of maternal deaths in Sierra Leone. The interventions that prevent it and treat it are available, low-cost, and teachable in a single training day. The barrier is not supply — it is consistent practice.

AMTSL — Active Management of the Third Stage of Labor

AMTSL is the standard of care for preventing PPH. It has three components, all performed in sequence immediately after delivery:

Condom-catheter uterine balloon tamponade

When AMTSL fails and PPH continues, the condom-catheter tamponade provides internal uterine pressure to stop bleeding. Evidence-based. Cost: under $2. All components available in Makeni.

06 The iCCM system and CHW network

The integrated Community Case Management system is Sierra Leone's primary mechanism for delivering child health services in rural areas. CHWs are the first — and often the only — clinical contact for families living more than 4 hours from a health facility.

The 4-hour trek reality

A child with danger signs in a remote chiefdom may be 4 hours on foot from the nearest PHU. The window between "danger sign present" and "child dies" is often shorter than that walk. This means the referral decision must happen before the family fully recognizes the emergency — and the CHW must make that call.

The single most important training shift for CHWs is moving from "should this child go to the clinic?" to "does this child have a danger sign that requires immediate referral?" These are different cognitive frames. The second frame requires the CHW to act urgently even when the family is hesitant, the child is still conscious, and the trek feels like a big ask.

The visual flashcard approach

Many CHWs in rural Bombali chiefdoms are themselves only partially literate. Text-based training materials do not work. Pictorial flashcards — one danger sign per card, illustrated — are the format that survives in this context. Each card should show: the danger sign (drawing), a short Krio caption, and a clear YES/REFER or NO/TREAT decision.

07 Equipment: what to bring, what's local

Pack for the gap between what permanent staff need and what exists locally. Do not pack for what would be useful in a fully stocked facility.

08 The Ebola and COVID legacy

The 2014 Ebola crisis killed more than 4,000 people in Sierra Leone and left a cultural memory that hospitals are places where people go to die. Facility utilization dropped dramatically during the outbreak and recovery was slow. In some communities, that memory persists. You will be entering health facilities where patients and families still carry this association.

Permission to touch

The "No-Touch" policy enforced during Ebola — necessary at the time — severed the physical contract between clinician and patient. The policy is gone, but its cultural residue remains. Washing your hands visibly, in front of every patient, before touching them is not hygiene theater. It is the act that re-establishes trust: "I am clean, I am safe, I have permission to examine you." Skip it, and you have broken a contract you did not know you were being asked to keep.

IPC waste segregation

Infection prevention and control failures after Ebola most often harmed cleaners and waste handlers — the lowest-paid, least-trained staff in the facility. The most common injury is needle-stick from a sharps container that was never sealed, or a bin that was overfilled. Teaching color-coded bin discipline prevents this:

Build Tippy-Taps outside every ward entrance. Install color-coded bins in every clinical space. Demonstrate high-level disinfection for reusable instruments (boiling, glutaraldehyde, or chlorine solution as available). Leave a laminated bin guide at each disposal point.

09 The 21-day schedule

This schedule is a guide, not a contract. The permanent staff set the pace. If they need to extend a session or repeat a training day, do it. The schedule exists to prevent the most common failure mode: spending too many days observing and too few days transferring skills.

10 What success looks like

Success is not measured on the day you leave. It is measured at 30 days, 90 days, and 12 months. These are the indicators that your work has taken root.

11 Who to contact in Bombali