The last post

All good things have to come to an end and so it is with my time in Sierra Leone. It has been an extraordinary experience which right now feels like a holiday romance. It has been short, intense and emotionally charged. Time has flown by and the goodbyes came much more quickly than expected. Now I’m left with the feeling that it should all be packaged up and consigned to memory because, however much you wish a holiday romance to repeat itself it would never the same second time around.

My experiences could have been very different and I was lucky to find myself with the King’s Sierra Leone Partnership. They were in Sierra Leone long before Ebola and will stay long afterwards so they have unique relationships with key stakeholders in the healthcare system.  I was also lucky to be there relatively early in the epidemic when holding centres were still being set up and I had the opportunity to be involved from early in the process. This brought its own challenges also many rewards.

The challenges for West Africa are far from over of course. First they need to finish off this epidemic which will be easier said than done. The current figures suggest over 20,000 infections and more than 7,000 deaths so far. In Sierra Leone alone at least 5,000 children have lost one or both parents and well over 100 front line healthcare workers have died. These numbers will continue to rise but hopefully at some point they will stop. Then will come the rebuilding phase, hopefully the two phases will actually overlap. There will be much to do. Schools, colleges and universities need to re-open, tourists need to be encouraged back and the healthcare system will need a major overhaul. I could see myself being part of that process at some point as I have been so taken by this country and its people, we shall see.

A wise woman once told me that you know you have met the right person if you can’t bare the thought of not marrying them. I see some parallels here. Of course I could bare not coming to Sierra Leone but I wouldn’t have liked it much and I would surely have been envious of those who had come. Time will tell if it’s a once in a lifetime opportunity but it’s hard to imagine history repeating itself in quite the same way so for me now there is just the final pleasure of travelling which is to return home.

Thanks to everyone who has read this blog. Feel free to leave comments and I will get back to you.

Tom

 

The middle of the middle

Several people have asked about the current state of the epidemic. There are various reports published by the United Nations and World Health Organisation which tell us that the epidemic has slowed considerably in Liberia and Guinea. Liberia has been reporting fewer than 20 cases per week recently, for example. Unfortunately Sierra Leone has not reached that point. It is true that in some Eastern areas they have not seen a case for over a month which is very reassuring. In Western area and Freetown however there has been no decline in cases although it isn’t clear to me whether they are still increasing. The bottom line is that the end of the beginning has probably happened but in Freetown at least we have not yet reached the beginning of the end. Perhaps the safest thing to say is that we are probably in the middle of the middle.

When the end finally approaches I’m pretty sure we’ll be stuck with a ‘last mile problem’. I suspect the number of cases will drop to low levels but there will continue to be isolated clusters of cases. Essentially healthcare facilities will have to continue to be on high alert an screen all patients at the front door. Suspects will still need to be isolated but an ever increasing proportion will be negative. When a small facility has not seen a confirmed case for a couple of weeks it might be difficult to avoid complacency but it must be avoided at all costs. It only takes one case to slip through to the wards to infect a new batch of healthcare workers and the cycle of fear and infection will restart. Similarly it only takes one unsafe funeral or a sick person staying at home with family and a new cluster will begin. I can see this going on for months and will be very tricky to solve.

One way or another, possibly with the help of a vaccine I think the end will eventually come and there will be a momentous day when Sierra Leone is declared Ebola free. I hope it will be in 2015 but can’t really be sure.  At some point more foreign healthcare worker will leave than arrive, tents will be taken down, command centres will close their doors and the whole relief effort will cease. If this were the Olympics we would have planned the legacy along with the main event. Given the speed with which this relief effort began it is only now that we might consider the legacy.

The legacy will have both a positive and negative side. To date 106 healthcare workers are known to have died in Sierra Leone. Given the scarcity of nurses and doctors before Ebola this is a huge number which will have a big impact on future services. There will also be a whole year with no nursing or medical graduates to fill the gaps. The economic and social legacies will be enormous; already nearly 5,000 children have lost one or both parents and the economy is on its knees.

So the negative legacy will be big but what of the positive legacy. Most of the health infrastructure was built in such a hurry that it is temporary and will have to be taken down. However, Ebola has shone a spotlight on this part of the world and reminded us what a poor state healthcare was in even before the outbreak. This can only help improve investment in healthcare going forward. While most temporary foreign workers will leave, some will come back as tourists and importantly some of us have been so enchanted by this country that we may come back for a much longer term deployment. 

What would you rather have?

Most professions have their own silly games. Doctors have a game called ‘what would you rather have’? There are 2 diseases and you have choose which one you would rather have. Most people go for something they are familiar with; I would always choose HIV over Type 1 diabetes but I’m yet to meet an endocrinologist who agrees with me. Both are incurable and may shorten your life span a little but HIV can be treated with 1 pill once a day whereas Type 1 diabetes requires multiple injections of insulin and measurements of blood sugar every day. To me that is a no brainer.

I was recently asked to choose between Ebola and multi-drug resistant tuberculosis (MDR-TB) and my first thoughts were ‘anything but Ebola’. But then I thought for a minute; in west Africa around 40% of people survive Ebola which is exactly the rate of successful treatment for MDR-TB in low resource settings. In high resource settings the survival rates are also likely to be remarkably similar, I would guess at around 95%. The treatment for Ebola is pretty basic and the duration short, whilst for MDR-TB treatment lasts 18-24 months and often comes with crippling side-effects. Put like this it becomes another no brainer, I’d take Ebola any time. 

Few things seem as scary as fighting in the First World War. Climbing Mt Everest might not seem the safest pursuit but surely it is safer than that.  Actually the chances of a soldier returning alive from WW I was as high as 90%, I had assumed it was closer to 10%, and the chances of returning home from an attempt on Everest are worse. And so it is with Ebola. What seems like the scariest disease in existence is actually on a par with something much closer to home. Ebola deserves all the resources and attention is has received but this conversation has reminded me just how much I have become accustomed to equally horrific illnesses seen in daily life. 

A life in the day of....

When starting medical school I had no idea what doctors actually did with their time, particularly junior ones. I think I imagined being in charge of my own ward and walking around making important diagnoses or something even further from the truth. I had no idea I would value my pen for filling in forms over my stethoscope or what a vital skill it would be to be able to un-jam the photocopier.

So what does a typical day in the isolation unit in Freetown look like at the moment? It begins with a check of the white board to see if there are any empty beds, with the number usually corresponding to the number of overnight deaths listed separately. Next is the clamour for results; all patients will have blood results pending which is often the rate limiting factor. No results mean no patient movement and an uneventful shift. Alternatively almost every patient may have a result. There is joy for the negatives who are cleaned, given new clothes and discharged with a certificate.  For positive patients it means an ambulance trip to a treatment centre which can be anything from 1 to 5 hours drive away. This can be terrifying for many who often start to pray wildly when given the news.

Empty beds must be thoroughly cleaned and linen changed before new admissions arrive. As I have said previously, selecting patients from the waiting area can be harrowing but sometimes there is relief when you can take everyone. New patients enter on foot, by wheelchair or on a stretcher. All need documentation, medication and a blood draw as well as information about how to stay safe on the ward.

Once this is all done there might be time to see each patient individually. I ask them about their symptoms as we can treat pain, nausea and anxiety quite easily. I also make sure they have a good supply of Oral Rehydration Solution and encourage them to drink, I often hear myself saying “drinking will save your life” which sounds dramatic but is probably true. If there is time I try to offer intra-venous fluids to some patients, these are carefully selected to be compliant and the most in need due to vomiting or profuse diarrhoea.

Deaths can occur at any time, there are usually 2-4 per day. Bodies need to be cleaned with chlorine and placed in labelled body bags that are cleaned again. The burial team come daily to collect the corpses for safe burial.

There are always meetings to attend and office work to do but the cycle repeats itself daily and I will be back checking the white board the next morning, once again looking for the empty spaces.

Heroes and villains

Alimamy Kamara- a cleaner in the Ebola isolation unit at Connaught hospital, Freetown

In humanitarian situations there are always heroes, they are usually local people who work hard and take risks to protect their community and country. They are rarely, if ever, ex-patriots. I have met a number of heroes in Freetown but the cleaners deserve a special mention. In the early days of the epidemic many worked unpaid to clean the high risk areas. This is a phenomenal sacrifice given that no-one was quite sure of the risks of infection and the mortality rate amongst healthcare workers was extremely high. Foreign healthcare workers like myself will be evacuated to a high resource intensive care unit if we become infected and that comes with a pretty good chance of survival. At that time the cleaners would have been placed on the ward like anyone else and suffered the same risk of dying, probably around 70%. Thankfully there is now a 12 bed unit in Freetown dedicated to treating healthcare workers and it has most of the trappings of a high resource unit. If this sounds like 2-tier healthcare then it is but it should not be criticised. There simply aren’t the resources to treat every patient with that level of care and it is vital for all concerned that healthcare workers feel as protected as possible so they continue to come to work.

Bilikisu is a nurse who survived Ebola infection and has returned to work in the isolation unit

The Stresses placed on local healthcare workers are also immense. All have seen colleagues die from Ebola but continue to enter the high risk zone, some have even survived infection themselves. Most disturbingly however, many face discrimination at home for their continued commitment to work with Ebola patients. A number have literally been barred from entering their own homes by their families and some have taken to sharing small rooms in the hospital as a place to sleep as they cannot go home. Compare this to the life of an foreigner like myself who gets almost daily affirmation from friends and family and you can see how truly heroic some of these people are. You can read some of their stories on the King’s Sierra Leone Partnership Facebook page- https://www.facebook.com/kingssierraleonepartnership

Of course there are no villains here. What I have witnessed though is the lack of co-ordination between partner organisations that I’m told is typical of disaster response. There is duplication of effort in some areas and large gaps in others. Sitting in meetings with the ‘Great and the Good’ it is clear that there are 2 types of doctor here. There are those who look after patients and those who talk about it. The latter are a frustrating bunch to say the least; they have fanciful ideas of what is possible and can even be critical of those involved in direct patient care. For those wanting to discuss clinical management it is vital to spend some time at the coal face before offering opinions.There are a number workers engaged in non-clinical activities and in vital areas such as vaccine research and epidemiology who should never enter the high-risk zone but for others it is essential. 

A second look

Bereh beach, beautiful but largely deserted

My first impression of Freetown was of life going on as normal but spend a few weeks here, talk to some locals and you realise life is anything but normal. To begin with the impact on the economy is huge. Some say the Sierra Leonian beaches are the best in the world, they are certainly spectacular but currently they are deserted as the tourist industry has collapsed. One of our drivers has seen his own taxi business implode and he now relies on working for the NGO to feed his children. Perhaps when this is all over a small silver lining will be that many new people have seen the country and would love to come back and visit.

Since May all schools, colleges and universities have been closed including the nursing college and medical school. Mass gatherings are outlawed so the football stadium lies empty although curiously church gatherings seem to be except. The bars along the beach are usually teeming with people and alive with loud music until the early hours but now they are almost silent. Just a few people prop up the bar with the quietest of sound systems playing, in truth they are supposed to be closed altogether. Even the public transport has changed; in Freetown cars are used as shared taxis to run along pre-determined routes. Normally there might be two in the front and another four in the back. To prevent too much body contact they are now restricted to one in the front and two in the back. Roadblocks are common and the rules strictly enforced.

At one point I wondered whether there might be perverse incentives for some people to keep the Ebola epidemic going, what with all the extra NGO’s floating around town hiring local staff. Nothing could be further from the truth. There are in fact far fewer NGO’s here than normal because all those not working on Ebola have understandably upped and left. It is true that some staff are being paid a ‘risk allowance’ but no-one I have spoken to values this above having their country back. You often hear people saying “after Ebola it will do this and that”, there seems to be an assumption that this will all be over sometimes early next year. Looking at the statistics I think we might still be running an isolation unit a year from now.

Risks and rewards

In the opening monologue of the film Trainspotting, Renton says “what people forget (about injecting heroin) is the pleasure of it, if it wasn’t pleasurable we wouldn’t do it after all we’re not stupid, at least we’re not that f***ing stupid”. On the face of it working with Ebola and injecting heroin don’t seem to have much in common but they do share the mixture of pleasure and danger which some people find addictive.

I’ve been highly introspective about my motivation for coming here and the reasons I enjoy it. One thing it definitely is not is altruism. That would mean incurring more risk than the rewards you get out at the end and I doubt many people are genuinely in that position.

The risks are hard to quantify but are real; while many local healthcare workers have died the mortality rate for foreigners who are evacuated to high resource settings is very low, in fact for those who recognise early signs of illness and are evacuated quickly the mortality rate is zero. That doesn’t take into account the terror of catching this illness and the concern it would cause to friends and family, not to say the cost, but it's some reassurance. I think that if the mortality rate for me was anything higher than about 30% I would be too scared to work here.

It has taken some deep introspection to work out the rewards that outweigh these risks. Firstly, there is definitely an adrenaline rush from being at the frontline of something really important. The outbreak has had devastating effects on west Africa and as a healthcare professional it feels like the most important place to be right now. There are always other places with competing needs and less media attention but right now this feels like the place to be. In short, if your normal life feels like the First division, this feels like a temporary shot at the Premiership. I can’t feel bad about that. It is true of many professions from the military to the media that you want to be ‘where the action is’ and I am no different.

There is more to it than that though. There is a side which feels like a guilty pleasure and that is the power and attention. I don’t like being the centre of attention at a social gathering, it makes me uneasy, but in a medical setting I think I enjoy it. My personality enjoys being the one out there in front of the hospital talking to the relatives in their time of need. I certainly don’t enjoy the power to decide who does or does not get admitted to the unit; that is something I could easily do without but being the one with the information and communicating with people at the gates is very rewarding and even intoxicating at times. That is difficult to share and doesn’t give me pride but I guess there are worse ways of satisfying a need for power and attention.

While my transition to the Premier league has felt pretty seamless I am not sure how easy it will to adapt to normal working conditions again. I common with many of my colleagues here I'm concerned that life back home might just feel too normal and bring on the depression that was expected after arriving here.