In Sierra Leone, palliative care services are provided by The Shepherd’s Hospice (TSH), Freetown (Table 1).

At the Shepherd’s Hospice, the range of services includes:

• Home based care
• Inpatient care (24 hour symptom control)
• Outpatients clinics (twice a week)
• Education and training
• Orphans and Vulnerable Children’s programme
• Women’s Wellness Project (WWP)
• Advocacy

During the 1990s, when palliative care was unknown in Sierra Leone, Gabriel Madiye became aware of lack of provision for patients who were terminally ill. In an attempt to find a way forward, he attempted to determine the disparate standpoints of those involved: health professionals, patients and relatives. It was from this base that the service developed:

Health care givers in Freetown, the doctors and nurses, they had a whole lot of stigma; they were discriminating against people living with HIV/AIDS and other terminal cases. Myths existed: that treating HIV infected cases and admitting them together with non-terminal cases might be injurious or harmful to the non-HIV cases. So the health care givers demonstrated the need for some sort of a place to isolate cases or, to be very informal, probably to say where they can dump terminal cases, and for somebody to be there as a governor to take care of those who could not be cared for within the mainstream of the health care delivery system. That was a need for the health care givers.

For the people living with HIV/AIDS and cancer, they needed compassion; they needed acceptance and they needed information: How long will I live? If I die today how can my property be protected against uncles who might want to grab it and possess it and leave my children without property? How long do I need to live with HIV and AIDS? Does being HIV positive means you are dying tomorrow? So their needs were principally centred on a need for compassion, for acceptance and information.

And for the family members, their needs centred on somebody to treat their relatives that were now sick; they wanted care at all costs, and they wanted professional medical care to be provided for their ill relatives.

Putting all these needs together we are able to plan and say, yes, if the Minister of Health and Sanitation is saying, ‘Let us have inpatient palliative care,’ or the health care givers want that to serve as a place where cases that are rejected within the main health care services could be accommodated: yes, fine – palliative care inpatient could be one service.²

Today, the hospice is housed in two adjacent three-storey buildings. Accommodation is as follows:

Building 1

• Ground floor: pharmacy, 4-bed female ward, 2-bed male ward
• First floor: administration offices, clinic office & resource centre/library
• Second floor: Training Hall

Building 2

• Ground floor: garage and store
• First floor: kitchen and dining room
• Second floor: smaller training hall/ resource centre, also used for fundraising activity

The wards are currently unused because of a lack of privacy (outsiders can see through the windows) and aggressive reaction towards HIV/ AIDS patients. Erection of a surrounding fence is seen as a priority.³

Ruth Cecil (clinical nurse specialist, palliative cCare) joined Sheila Hurton (Princess Alice Hospice) and Jacqui Boulton (SRN and midwife) on a visit to The Shepherd’s Hospice in January 2004 and subsequently wrote:

Driving through Freetown and along Kissy Road I saw the war damaged buildings and the offices of some of the 106 NGOs said to be helping re-build Sierra Leone following the war.

Sierra Leone has few doctors and nurses as many leave to work in Europe/ USA. Capacity building is a term used for the dissemination of knowledge, in this case of HIV/AIDS prevention and care and palliative care.

What is happening in Sierra Leone is excruciatingly shocking. The battle against HIV/AIDS is taking place in a climate of denial and lack of basic resources. I have great admiration for the work of TSH and its staff. This work includes sensitisation to combat the stigma associated with HIV/AIDS. It is this stigma connected with job loss, family rejection, and social ostracism, which prevents people taking the AIDS test and seeking help. Education about HIV/AIDS and its prevention, and schooling for AIDS orphans, are also tasks undertaken by TSH.⁴

Jacqui Boulton comments:

We continued to get a feel for the work of TSH by visiting the Women’s Wellness Project at Tombo, a village outside Freetown. The project seeks to provide something positive for women who are diagnosed with HIV, integrating them with women from other vulnerable groups to provide literacy, numeracy, life skills and health education. In response, they agree to act as ‘peer educators’ in the community.

I was fortunate to spend a morning at the United Methodist Church Maternity centre. This is one of the hospice partner institutions with staff seconded to TSH for training. I was shown around by Isata, a student midwife who had attended our training course and who was now responsible for counselling those pregnant mothers agreeing to be tested for HIV. On the morning of our visit 84 women were waiting in the antenatal clinic. These would be seen on a first come, first served basis and some were asleep having arrived from 6am. As an incentive for attendance, the mothers received a helping of yoghurt eaten in the presence of a uniformed nurse!⁵