Thorlie turned wordlessly in the darkened room and lifted his gloved hands. Sweat beaded up on his forehead like dewdrops. A nurse reached into the surgeon's pocket and pulled out his penlight, a pas de deux they had clearly performed many times before.
An aide was dispatched to start the generator and, eventually, a few low lights flickered on in the operating rooms. The rest of the hospital remained dark.
The power had failed two nights before, but no one on duty knew how to operate the generator. So Thorlie had awakened the deputy health minister, who woke the minister of energy, who contacted the electrical substation and got power restored. (The substation, it turned out, had taken a bribe to divert electricity to another neighborhood.)
It was an all-too-typical week at Princess Christian Maternity Hospital, which takes on the most difficult cases in a nation of 6 million.
Told of those events the next day, Sierra Leone's first lady, Sia Koroma, a trained nurse, sighed. "It's hair-raising, but it's true," she said. "And that's one of the government's best hospitals. The others are worse."
Bypassed by prosperity
Living standards are improving across much of the world these days. Free markets in Southeast Asia and Eastern Europe have transformed those regions into economic powerhouses. A high-tech revolution in India has lifted millions into the middle class, and the quality of healthcare has improved in the unlikeliest of places.
That tide has mostly bypassed sub-Saharan Africa. More than $1 trillion in foreign aid -- a major chunk of it from the United States -- has been pumped into Africa over the last half-century. Yet, on most of the continent, people are poorer and less healthy than before.
Since Sept. 11, 2001, world attention has been focused on the danger posed by disintegrating states such as Afghanistan, Pakistan and Somalia. Some lesser-known developing countries, though, also are incubators of strategic threats, including terrorism, narcotics smuggling, human trafficking, the small-arms trade and public health crises.
West Africa is of particular concern to world health officials. With shortages of medicine, trained doctors, reliable electricity, clean water and such basics as sterilized gloves, countries often lack the means to identify and deal with new disease threats.
"As we turn over more and more rocks in more and more places, we find more passages for disease," said Dr. Scott Dowell, director of global disease detection at the U.S. Centers for Disease Control and Prevention. "Most aren't going to be the next HIV or SARS, but it's pretty hard to tell which ones will and which ones won't."
Money and corruption
Sierra Leone is one of those nations where decades of foreign aid have failed to appreciably lift the fortunes of the people. The country is a charity case: 60% of its public spending comes from foreign governments and nonprofit organizations. Since 2002, it has received more than $1 billion in aid.
Yet it has the second-highest rate of infant mortality in the world, behind Angola; even Afghanistan ranks lower. The United Nations says 1 in 8 women die giving birth in Sierra Leone; the rate in the United States is 1 in 4,800. Life expectancy in Sierra Leone is 41 years; in Bangladesh it's 60.
A decade-long civil war in the 1990s drove people from the countryside into the capital, Freetown, and today a city built for 250,000 is home to 10 times that number. Tens of thousands camp out in shacks on a lush mountainside with views of the Atlantic but no clean water or electricity.
The war compelled thousands of the most educated Sierra Leoneans to go into exile in the United States and Britain. They make annual visits home, where they are known as the JCs, for "Just Comes," and are both envied and resented. A few have moved back, some to cash in on their contacts with government ministers who oversee the country's diamond and gold reserves.
The country managed a democratic election in 2007, but widespread corruption makes international donors wary. President Ernest Bai Koroma, a businessman who fled to London during the war, has cracked down with mixed results. After a judge accused of bribery was recently arrested in his chambers, lawyers pushed for rules to prevent police from arresting judges in the courthouse.
A few months ago, a 6,200-ton shipment of donated rice from Japan disappeared soon after arriving in port. When $10,000 disappeared over the summer from a project to alleviate child poverty, the director threatened to pull the plug if the money didn't reappear. It did.
But the director, Fadimata Alainchar, says that "people here are in it for themselves, and it's difficult to see that changing."
The sorry state of the country's roads has limited development. In the capital, cars and SUVs inch along narrow roads swarming with pedestrians. There are no traffic lights.
Outside Freetown, the major thoroughfares are rugged tracks of dirt and chunks of concrete. On one of those roads, a 63-year-old man named Jonathan Harding was using rocks he dug from the countryside to shore up a turn washed out by heavy rain. He once worked on a highway maintenance crew, but was fired for accusing his boss of corruption. Now he gets by on tips from passing motorists.
Even traveling to Freetown from its international airport is daunting. The distance is only 10 miles, but by land it takes at least four hours. A ferry is quicker, but often out of service. Water taxis make the journey, but frequently capsize. Most travelers use a private helicopter service, which charges $70 each way. Vintage Russian-made choppers, carrying 18 passengers each, complete the journey in a tense, thundering seven minutes.
There are a few signs of economic life. Wealthy businessmen and government officials keep two nightclubs, Old Skool and the Office, thumping until dawn, with Playboy videos on flat-screens, top-drawer Scotch on the shelves and Lexus SUVs in the parking lots. Large mansions are going up on the outskirts of the capital.
Michael Kargbo, a Sierra Leonean who ran a construction company in New Jersey before returning five years ago, says he has $1 million in construction projects underway, and his crews are building homes for government officials and the business elite.
"Most of the guys in power today are guys I either went to school with or knew in the States," he said, pausing at the site of a two-story hillside home under construction. As he spoke, Koroma's motorcade, escorted by soldiers with sirens and flashing lights, sped by. From his Mercedes, the president waved to Kargbo, who smiled and returned the greeting. As the motorcade disappeared, Kargbo said, "Business is good and getting better."
For some, perhaps. But the country remains a political tinderbox. Tens of thousands of former child soldiers, who were forced into militias that killed, raped and hacked off the limbs of victims, have melted back into society. Some, like Lamin Bangura, who became a rebel fighter at age 12, now drive motorcycle taxis, known as okadas, in the capital.
"We used to steal, but now we can make a living," said Bangura, 27. A dangerous living. Okada drivers are harassed by policemen seeking bribes and taxi drivers who resent the competition.
But large numbers of those former rebels are unemployed, and their anger, combined with their military training, poses a threat to political stability.
"We have been stigmatized by society and the government turns a blind eye," said Kabba Williams, 24, a college student who leads a group of onetime child soldiers lobbying the government to create jobs. "If there is a war, and someone is looking for mercenaries, they can find them right here, unfortunately."
The precariousness of Koroma's position was clear early this year when he left the country for unspecified medical treatment in India. His rivals attacked the headquarters of the president's party in a downtown melee involving 5,000 youths.
The government feared a coup was in the making and prepared to respond with force. But Michael von der Schulenburg, the U.N. secretary-general's representative in Sierra Leone, drove to the scene and brokered a resolution. Later, the president and his opponents signed an accord pledging support for democracy.
"If we can prove that here, in the poorest country in the world, there is a possibility to go from conflict to democracy and stability, it would be an example for other countries," Schulenburg said. "We have to keep it stable at any price, because Sierra Leone could easily become another Somalia."
'So many problems'
The most immediate crisis, though, is healthcare. The country has only two pediatricians, and Thorlie is one of four obstetricians. All work at Princess Christian.
Doctors Without Borders set up clinics in Bo, the second-largest city, during the civil war. Now it's time to begin pulling out and move to other countries in crisis, but Jan van't Land, the local director, says he's worried.
"We're in a difficult situation," he said. "If we leave, who would take over? It might create another crisis."
When Koroma took office in 2007, his wife, Sia, launched a global effort to draw attention to the public health crisis. An oil industry chemist before the war, she started a career in nursing during the couple's years in London. Her evangelical work has brought some help, but she acknowledges that progress has been slow.
"We are faced with so many problems -- illiteracy, poverty, youth unemployment and the need for gender empowerment," she said. "I'm trying to be an advocate for women and children, because they are the most vulnerable."
The first lady's office in the hilltop presidential lodge recently was filled with donated items, including sewing machines and farm tools. Outside, next to the first couple's empty swimming pool, a dozen hospital beds were stacked under an awning. The healthcare system needs a lot more than a few beds, though.
Government salaries for doctors range from $100 a month to $200 for specialists; experienced nurses earn $80. The salaries are among the lowest in the world; doctors in Ethiopia, Liberia and Nepal make more than four times as much.
To supplement their salaries, doctors negotiate payment with patients before treatment, and at the end of each day share that money with nurses and aides. If the patients don't pay, the doctors give the nurses money from their own pockets. Otherwise, Thorlie said, they won't show up.
"It's the worst thing in the world for a doctor to have to discuss payment with his patients," said Thorlie, who has been chief of medicine at Princess Christian for 25 years. "If two people come to me with a fever, and one agrees to give me 10,000 leones [about $3], who do I treat first? This situation is bad for us, and it's bad for patients."
In practice, he says, he and his doctors treat all patients, paying or not. "But for those who can afford to pay, they should pay," he said.
That sentiment has put him at odds with the Ministry of Health.
"Our policy is free medical treatment, and we have to enforce that policy," said Sheiku Tejan Koroma, appointed health minister in March. "We know that our salaries are the lowest on Earth and we need to increase them. The problem is that we don't have the money." But, he added, "this is a corrupt system we've inherited and they are more interested in their salaries than in their fellow man."
The health minister was an engineer at Texas Instruments in Dallas when President Koroma (no relation) asked him to return to Sierra Leone. His wife and three children stayed behind because he wasn't sure how long he would last. "My kids e-mail me that they want to buy expensive shoes, but I only make $500 a month," he said. "I told the president: If we don't make progress, I'm out of here."
A little over a week ago, the health minister was indicted on charges of illegally awarding contracts.
A doctor's frustration
Princess Christian Maternity Hospital is a sprawling concrete structure behind a guarded gate on one of Freetown's busiest downtown streets. Stray dogs roam the dirt courtyard, and windows in the hospital wards are cranked open to the outside air.
Thorlie, who presides over a staff of 12 doctors, wears a pressed dark tunic and a perpetual expression of weary stoicism. Though many of his colleagues left for lucrative jobs in the United States and Britain, he decided to remain in his home country. "If I didn't stay," he said, "who would?"
He was speaking in his office, where he relaxes by listening to country music. Jim Reeves' "Not Until the Next Time (Will I Cry All Night for You)" was playing on his computer.
Thorlie has grown increasingly frustrated with the Health Ministry. He had a heated argument with a ministry official recently over a proposal to outlaw home births to help reduce the infant mortality rate.
Expectant mothers in Sierra Leone often rely on "traditional birth attendants," untrained women who don't know when to refer patients to hospitals. Thorlie agreed that women need to be encouraged to come to clinics, but he argued that criminalizing home deliveries was not the answer.
"In dealing with human beings, you can't just force them," he told the ministry official. "You need their consent."
One of the obstetricians at Princess Christian, Dr. Kamson Kamara, was an emergency room doctor in Oklahoma City earning $120,000 a year when he decided to return to help his country, in a job paying $2,400. His wife, a dentist, and two children remain in Oklahoma.
The difference between his old job and this one "is the difference between earth and sky," he said, sitting in the doctors lounge between surgeries. A hospital aide knelt on the floor wiping splattered blood off the doctor's shoes -- and off a floor lamp that Kamara brought from home to use in the dimly lighted operating rooms.
"It's really pathetic," he said. "People are dying here and it's getting worse every day."
Two nurses appeared and Kamara reached into his pocket, giving each a few bills of the local currency. "I have to keep them happy," he said.
One more statistic
After the recent power outage, a pregnant 19-year-old named Maiatu Kabia was wheeled into the operating room. She was suffering from eclampsia, a life-threatening complication of pregnancy characterized by convulsions. The family had refused to give doctors permission to operate earlier.
Dr. Prince Masuba, 34 and a year out of medical school, started a C-section. He and two nurses worked for 10 minutes to push the baby out through the incision. "I don't think this baby is alive," he said.
Eventually, the stillborn baby was placed on a tray near his mother. A nurse made notations in pencil on Kabia's chart: "Uterus closed and stitched. Placenta removed. Wound closed in layers."
Six hours later, Kabia died in the recovery room.