Friday, 1 May 2015

The London Marathon - a great little finish to my time with King's Sierra Leone Partnership

My legs have just about recovered but I’m still on a complete high from running the London Marathon on the weekend. I was fully prepared with all these little psychological tips to get me through the pain and to spur me on when I ‘hit the wall’ but I didn’t need them. In between spotting my amazing entourage of friends and family around the course, thoughts of King’s Sierra Leone Partnership, Idrissa and my two team mates – Amelia and Brendan (who ran all the way in his PPE, what a legend!) up ahead, certainly kept the “fire burning”. I feel like my cheek muscles had just as much exercise as my legs from all the smiling! Various people had said that the crowds would be a huge help and that couldn’t have been more true. I felt tears prickling my eyes as I crossed Tower Bridge simply knowing that all these thousands of spectators were supporting individuals like me with similarly personal and important causes, just like mine. So a massive thank you to everyone who came to cheer and an even bigger thank you to everyone who kindly and generously donated to King’s.
At 10km when I took off the PPE. Brendan wore it ALL the way. Legend!
All smiles... Brendan, Amelia and I, together we have raised £17,279.38 (incl. Gift Aid) for KSLP. 

Sadly my time with King’s has come to an end, for now at least. I’d love to be able to move on knowing that we are safely post-Ebola but unfortunately that elusive status still seems quite a distance away. It’s amazing how out-of-the-loop I feel not living, breathing and working every moment in the office where at least someone is talking about Ebola every day. There were 6 positive cases of Ebola in Freetown last week, ending 22nd April. Despite the huge increase in numbers of epidemiologists tracing every contact of a positive case, still more than half the new cases in the week ending 15th April came from unknown transmission routes. The ongoing vigilance of all the healthcare workers and the country as a whole is so important, but has got to be fairly tiresome. Yet there are little signs of hope, as my neighbour from Freetown sent me a picture of her son in his school uniform on whatsapp, proudly going to school for the first time in 9 months. Her words ‘really sister, I am so happy for that’ emphasise the impact this deadly virus has had on all aspects of daily life.

Leaving Party for Paddy, Aatish & myself in my house
in Freetown with all the Isolation Staff from Connaught
I can’t thank the other volunteers in Freetown and the London office enough for all the support, friendship, career advice, cooking tips, media training… what an amazing few months! I have had a brief insight into knowing how intense it can be working in an environment where you can see how much there is to do but can only make progress one step at a time. I have the utmost respect for the volunteers and staff who have the dedication to stay and help, especially now so many health system strengthening projects are up and running (A&E, Mental Health & Infectious Diseases, not to mention the IPC programme!). If you know anyone who would like to join the team, King’s are currently recruiting for a number of positions including Country Director and Senior Nurse. I also feel completely humbled by the dedication of the local staff who work tirelessly day in, day out without the easy option of leaving when they feel like they’ve had enough. Their commitment to working in the unit, not getting despondent and seeing the end of Ebola is inspiring. All in all, I’ve met some incredible people that I hope to stay in touch with and visit again in the not too distant future.

Idrissa and I at my leaving party
Finally, the last word of my blog for now, is saved for Idrissa, whose words of ‘you are strong, Claire’ followed me round the roads of London on Sunday. Amelia, who also trained with him last summer, and I rang him from the post-race reception and he simply squealed down the phone with excitement. This was how he must have felt after completing the London Marathon himself last year. Thankfully, he does have something to train towards now. Tom Boyles, the South African doctor that trained me in using PPE when I first arrived in Freetown, has set up an initiative to raise funds for Idrissa to train in Kenya in preparation for running the Cape Town Marathon in September. Hurray! I will circulate the link to the fundraising website when it is launched shortly.

Thank you to you all for reading my blog. I have had some very kind words of appreciation over the last few months. I’m not going to lie, I have not found it easy to keep it up to date but I have appreciated the opportunity to reflect and share some of my experiences. I don’t know yet whether I will continue to blog from England or not yet, maybe it will be the next time I am overseas… we shall see :)

Friday, 17 April 2015

So what is IPC?

I don’t think I have ever written, spoken or thought about three little letters as much as I have in the last few months: IPC… Infection Prevention & Control. Since mid-December I have been helping establish and initiate implementation of Sierra Leone’s first ever National IPC Programme.

I think one of the most important positive outcomes of the Ebola epidemic has been the general introduction of the backbone of IPC, hand washing, into multiple aspects of people’s lives. In Freetown, as you enter hospitals, shops, restaurants etc, you are often asked to wash your hands using the buckets of chlorine or sometimes ‘Detol’. The other day, I watched a family enter a cafĂ©, and the dad endearingly held up his small children one at a time to wash their hands using the chlorine bucket before entering. This has got to be one positive consequence of Ebola.

In the hospital setting, the changes to daily work have been more visible and intrusive. There is now a generally unspoken understanding amongst all healthcare workers that you should not touch a patient unless you are wearing gloves. All patients who have screened ‘negative’ i.e. they don’t have symptoms that meet the Ebola case definition, are met in A&E by an anonymous muffled voice behind a barrier of PPE – a facemask, gown, double gloves, and apron. This is the national recommendation within the recently approved Standard Operating Procedures for ‘Basic Healthcare in the context of Ebola’. It is just in case Ebola patients slip through the net of the screening process. With the number of healthcare workers who have been infected and lost their lives in the epidemic in the hundreds, just in Sierra Leone, it is completely understandable that they must protect themselves as much as possible. But what impact has this had on the human touch of healthcare? I certainly know that it will initially feel bizarre, almost wrong, to touch a patient without gloves on when I come back to working in the NHS.
Interactive training sessions – IPC Focal Persons from each government hospital attended a 2 week training course in Freetown in March
So I feel like I should explain a bit more about the IPC programme I have been working on so much causing me to neglect my blog (sorry!).  It has been exciting to be part of this programme from almost the very beginning. The Ministry of Health & Sanitation has elected a National IPC lead person in the Ministry and 25 IPC focal persons (mainly nurses) in the 25 government hospitals in the country. Each focal person is responsible for setting up an IPC committee in their facility and rolling out training for all healthcare staff. Each focal person and hospital has an international mentor and partner organisation (that’s where I come in with King’s) to help support the roll out of this programme. The international mentors and the IPC focal persons attended a two-week IPC training programme at the beginning of March. This was a great opportunity to form working relationships between the mentors & focal leads, and also share some teaching tips in how to engage classes in more interactive style of teaching. I met so many incredibly determined and passionate individuals, mostly women :) who are going to be the tour de force for IPC in their hospitals. As IPC is a relatively new concept in Sierra Leone, my hat goes off to these IPC leads who have a huge challenge ahead of them. And yet the training course was full of optimism and momentum for change. Following the training we are in the process of trying to organise training for all staff.  At Connaught, this is nearly 800 people. 

Training – how to clean spills
in a non-Ebola hospital environment
Oh sorry, I still haven’t really explained what those three little letters mean… it’s basically all ways of preventing the spread of infection between patients, from patients to staff and from staff to patients. It includes everything from basic hand washing to making sure used needles are put in ‘sharps boxes’ safely, segregating clinical (possibly infectious) waste from general rubbish, to the provision of Hepatitis B vaccine for staff prophylaxis (something that currently does not happen in Sierra Leone) and appropriate use of antibiotics to prevent resistance developing. It really is a huge topic and in a healthcare system that struggles to get enough gloves per nurse at the beginning of the day, it’s difficult to know where to start!

What it is certain is that behavioural change, like making sure nurses dispose of sharps safely every time, does not happen overnight. There will be trainings and more trainings and more trainings and bit by bit we’ll get there. The other thing that is very clear is that all the trainings in the world are not going to achieve anything unless the systems are in place for implementation. This is a huge project. There are funds available through two different grants (USAID & DFID), in all government hospitals to improve the Water, Sanitation & Hygiene (WASH) infrastructure. Needless to say, if a hospital has no reliable running water then hand washing is going to be quite difficult. All of the four hospital sites with which we have been working with have differing degrees of complex infrastructural problems.  We are lucky to have Gerard, a volunteer Engineer, working with King’s since February who is going to help sort a lot of these issues out. No pressure! 

It has been really interesting to sit in some of the ongoing funding and planning meetings in the last few weeks. There has been a tangible shift and transition away from the acute emergency phase of the Ebola epidemic and towards the long-term recovery into development phase.  What is also interesting is the sheer number of international partners (UNICEF, UNDP, WHO, CDC, OXFAM and smaller NGO’s like ours) all competing for funds and projects and the co-ordination nightmare this creates. Even within the IPC world, there are parallel IPC programmes which cover trainings in hospitals, in peripheral health units, in communities and also setting up IPC focal leads at the District level. I had read that co-ordination of aid can be difficult but until now I had never appreciated the scale of the politics involved in humanitarian, and, increasingly, development aid even at a ground level. Despite this, real tangible improvements are achievable through this programme and it is with a heavy heart that I am leaving Sierra Leone just when trainings & WASH projects are getting going.

I am so pleased to have been part of this important step forward in Sierra Leone’s health system but I need to hand-over to a fantastic team of nurses who will carry on with this project for the whole year. I have met the most amazing people from the Ministry, the co-ordinating NGOs, at King’s and the IPC local leads at the four hospitals through this project. I wish them all the luck in the world in their tremendous challenge of improving the country's healthcare system one step at a time, starting with IPC.  

Saturday, 14 March 2015


We hear the word ‘hero’ bashed around quite a bit out here. I find it rather awkward – like we (although I’d much prefer to refer to the local staff rather than us, international folk) have some sort of special power. The British Embassy even cashed in on the term last week, hosting an “Ebola Heroes” night of thanks to the UK teams involved in the response. It’s a shame that the term, for me, has become overused and degraded somehow. When you describe each and every Ebola worker as a ‘hero’ it gets a bit tiresome or we all just get a bit arrogant which has got to be worse.  I really don’t mean to undermine the amazing work that lots of healthcare workers are doing here; entering the red-zone on a daily basis takes a lot of courage. The recent news of a British military healthcare worker infection reminded me of the ongoing risk we face. In fact, following that news, I vividly dreamt I had Ebola the night before last and woke up in a cold sweat. That used to be a fairly regular dream for me when I first arrived but I had obviously come accustomed to the risk and possibly less daunted by the prospect. There’s nothing quite like a military personnel getting infected, with all their resources and protocols, to realise you can never fully eliminate the risk.

Talking about heroes of different kind… do you know who my hero is? A gentle, kind and fiercely determined young man called Idrissa. In the depths of my despair about my marathon training a few weeks ago, I was quite literally in tears in the office and Oliver asked what the matter was. Oliver is the programme director of King’s Sierra Leone Partnership – an amazingly pragmatic person and deservingly well-respected here. His response was quite simply “well, you need a personal trainer”. Within a minute or two he had rung a friend of his and fixed him to be my trainer.

Idrissa Kargbo is not just an ordinary personal trainer. He’s Sierra Leone’s top long-distance runner and at the mere age of 25 (or 24 or 26, he’s not quite sure of his birthday) he has a potentially exciting career ahead of him. He was ‘spotted’ by an Australian girl called Jo (who used to be the King’s media person) and through her own fundraising and the competition money of winning the Liberia marathon he managed to get a place in the New York Marathon in 2013 and London Marathon in 2014. In London, it was a super hot day which suited him perfectly as he’s used to the heat in Freetown, he ran his personal best of 2 hours 32 minutes. That happens to be the exact time I ran the Great North Run (a half marathon!) during medical school. I have, since then, done a half marathon in sub-2 hours (just: 1 hour 59 mins and 50 secs!), but Idrissa really does run twice as fast as me.

For now though, unfortunately and very frustratingly, Ebola has prevented him entering any international marathons this year. He also doesn’t have the funds to pay for flights, visas, and competition entry fees. He barely has adequate equipment to run here - his Garmin watch, a gift from an British friend, broke a few weeks ago and he cannot get a replacement for now. The recent news of Jimmy Thoronka, the Sierra Leone Commonwealth Games athlete who ‘absconded’ in Glasgow last year and a sadly similar story of one of Idrissa’s London Marathon co-runners and friends, Mamie, are both examples of the desperate lengths these individuals take to leave Sierra Leone but only to the detriment of their career. If only these exceptional athletes could be recognised and supported by their own government they may not have been driven to running away. It would be incredible if there were some way of securing long-term sustainable funding Idrissa's running career; he can only so far without any professional training; running the chaotic hilly streets of Freetown. If anyone reading this blog has any suggestions of how to support Idrissa - please contact me.

Without a race to train for now, Idrissa seems happy enough to earn a bit of cash from me and jog alongside my comparative snail-pace four times a week. His love of running is certainly infectious. He’s always got a smile on his face, even at 6am in the dark and I’m already complaining, “I’m tired” before even setting off! He has some pretty fantastic stock phrases, “Keep going, keep the fire burning” or “You are strong, Claire”. Yet at other times, he’s perfectly happy to bring attention to the fact that I do run, in fact, really slowly! The other day, he insisted very sincerely, that on race day in London, “all you need to do is find a really old man, and run behind him all the way”. Ha! Thanks Idrissa. He meant it so endearingly and so wants me to cross that finish line ‘strong’ but telling me a run like an old man isn’t particularly encouraging! I am so grateful for his support though as I know I couldn’t motivate myself to get out running four or five times a week without him.

I should add a little disclaimer - my 3 mile run (15 mins pace) was a serious crazily steep hill training session!

The race is 6 weeks tomorrow. I ran a half-marathon this morning in just over 2 hours and actually felt remarkably good, both mentally and physically. The plan is to scale-up distances over the next 2 weeks until our last training run together on the 30th March when he wants me to run 20 miles. Eek, ‘keep strong’…

Please sponsor me: – all funds raised are going to King’s Sierra Leone Partnership. Thank you.

Sunday, 1 March 2015

What is a safe and dignified burial?

I warn you this is a rather bleak and factual blog entry… You may have seen or heard on the news that all burials in Sierra Leone are required to be ‘safe’ during the current state of emergency. This is certainly meant to be the situation – but what is a ‘safe’ burial and how does it differ from any other? What is the impact of the change in burial practice on bereaved families? What can be done to help give a dignified burial?

I was lucky enough to meet the perfect person who could answer these questions; Trevor works for Concern Worldwide and manages the Kingtom Cemetery, the largest cemetery in Freetown. Kingtom is situated right on a small headland in the centre of the city’s coastline. Originally named after a tribal chief by the same name, Kingtom has had a cemetery for many decades but since the start of the outbreak it has become the most important site for ‘safe’ burials.  The daily and overall organisation of the cemetery by Freetown City Council and Concern Worldwide has been key in preventing onwards transmission from Ebola corpses, which are extremely contagious and thought to be one of the main causes of transmission.


In order to understand the process more thoroughly Trevor recommended that Grace (one of the other KSLP volunteer doctors) and I should join the Burial Team to follow what happens when a corpse is collected from our Isolation Unit.  So on Thursday, we met Alie, a warm-hearted friendly Sierra Leonean who has worked for the Burial Team since the very beginning of the epidemic. He must have worked through very tough times in the last few months but he was amazingly approachable, calm and patient whilst on the job.

The burial team arrives at Connaught Hospital
When someone dies in our unit the first thing to do is to inform the family. Over time I have learnt it is better to tell the male relatives first, preferably the eldest or head of the family if they are available. The men will then either tell the women themselves or ask you to break the news but at least they are ready to console the women as emotional outbursts of crying and wailing are likely to ensue. This is really hard, the wailing can often be heard from across the other side of the hospital grounds and it haunts you wherever you go. 

If a blood sample has not already been taken before the person died then an oral swab sample is taken to test for Ebola. Unfortunately these swabs are not 100% reliable, for example due to inadequate sampling or failure due to chlorine contamination. It is at this stage that a difficult dilemma often arises… relatives often want to wait for the result of the blood test and/or swab before the person is buried, so that if negative they can give them a ‘normal’ funeral. However, during my time with the burial team, I came realise that there is no such thing as a ‘normal’ burial any longer in Sierra Leone.

Burial Team get into PPE to collect the body from the Isolation Unit

Burial team
The corpse(s) get collected from the Isolation Unit by the burial team, who arrive in two vehicles; one van with stocks of PPE and chlorine and 4 or 5 men crammed in the back and one open-air truck with some tarpaulin sheeting to cover the body bags. The burial team gets dressed into PPE and collects the corpse in a white body bag from the mortuary inside the unit. They then decontaminate by the vehicle using a method that seemed very rushed and flawed to me and yet it is a process they are familiar with having done this day in day out for months.

Grace and I followed this open-air truck around the corner to the Connaught Hospital Mortuary where the burial team were going to find out if there were any other bodies to be buried. The Mortuary, just next door to our KSLP office, is for patients who die on the general wards or for the community in general, e.g. accidental deaths. Inside the Mortuary every corpse has an oral swab sent for Ebola and is then transferred to a body bag for ‘safe’ burial. This means that the earlier dilemma of waiting for a result in the Isolation Unit doesn’t change things greatly for families, although it may give them an extra day or two to organise a coffin since body bags are allowed to be buried inside coffins.

Grace and I were welcomed inside the Mortuary and given seats in the director’s office since we were there to observe the burial process. We spent the best part of a very uncomfortable hour observing the manager explain the burial process to the bereaved parents of a child who had been killed in a road traffic accident that morning and then to the family of a patient who died on the wards. The manager alluded to a small, but nevertheless very significant, caveat to the safe burial procedure when he suggested corpses could be released to relatives for, presumably, normal non-safe burials if the swab tests are negative and they get a certificate from a doctor. We were shown the required certificate: a flimsy piece of paper filled in by hand that could quite easily be forged. This flaw in the system is something that will be clamped down on next week as a new media campaign is starting to emphasise the need for 100% safe burials in Sierra Leone. 

(In fact, a couple of days later whilst another Kings volunteer, Dominic, was visiting the cemetery he witnessed a fake burial team turn up at Kingtom. They were wearing dubious PPE that they kept taking on and off. The body was wrapped in a sheet (not a body bag) and when questioned they said, “We are the Connaught burial team” which was an obvious lie. The police where called and arrested them on the spot whilst the driver did a runner! We have no idea who they were but the whole scene sounded very bizarre; why turn up at the official cemetery and do a bad job of pretending to be official? More worryingly, despite all the media campaigns and the devastating epidemic for 8 months, people are still intent on bending the regulations.)

Following the burial team (Toyota) to the cemetery
Anyway eventually, thankfully, Grace and I excused ourselves from this manager’s cramped office which reeked of formaldehyde and waited outside for the burial team to move one more body from the mortuary into the back of the van. This was someone who had died on the normal wards but for all purposes was treated exactly the same way: swab, body bag, full PPE… so “safe burial”. Then we followed the van through the streets of Freetown to Kingtom Cemetery, about a mile away. Little did people know that there were two corpses under the tarpaulin and a bag of contaminated PPE on top as this vehicle crawled its way through the crowded streets of Kroobay.

Creating more space; excavating the rubbish dump
Kingtom Cemetery is a wide-open area of graves much like any other cemetery. However, on one edge, the cemetery is a daily hive of activity, as it now has to expand rapidly to accommodate all of Freetown’s deaths. It was here that we met Trevor and he kindly showed us around. I felt quite unsettled, as if I were an ‘Ebola tourist’ but Trevor reassured us that it was 100% fine to observe and even take photographs. The cemetery’s perimeter fence is covered in black plastic sheeting to block the view of the rubbish dump behind, giving at least a little visual dignity to the fact that the extra space required has had to come from somewhere. Fifty metres from where the current graves are being dug and filled there’s a big tractor tearing through the years-old layers of a landfill site making space for more. But Trevor tells us they are running out of space. There’s a new site at Waterloo, half an hour drive to the East, which will take over when Kingtom has reached capacity.

Limited space available

A safe burial
I suppose it’s not very often you consider the daily mortality rate of a city. Certainly in the half an hour that I was there, I was amazed to see a number of burial teams bring in at least five bodies and bury them in the same amount of time. There are various practices that have developed over the course of the epidemic to allow families to say goodbye as best they can. They are allowed a maximum of ten relatives to attend the graveside, where they watch the teams in full PPE bring the body bag from the van to the grave. Muslims can be buried with a white cloth, and Christians can be buried in a coffin but they are buried alongside each other, whilst an Imam or a Priest guides the relatives through prayers from a safe distance. 

Once the body is placed at the bottom of the grave, the burial team decontaminates throwing their used PPE in the grave and then, quick as anything, the gravediggers fill the grave with soil. It was a sadly unemotional procedure to watch. The relatives helplessly stand by and watch, hopefully with some indication of which body bag belongs to their relative as it is carried to its grave. 

Trevor and Grace walk past recent burials

Concern Worldwide will be providing gravestones for each grave, but until those are in place they are currently being marked with a name on a wooden stick and a number. There’s also a small area with white fencing to one side which contains a number of graves from the beginning of the epidemic when there were just too many corpses and too little infrastructure to organise one body per grave. There are plans to make a plaque to indicate the names of all those buried in that area.

I came away feeling cold and deeply saddened by this epidemic and its consequences for all. I cannot imagine what it must feel like to be told one morning, “your brother/father/mother/daughter has died, possibly of Ebola (but we won’t know for a few days), and you have to follow this burial team, who will bury the body like every other body in a white heavy duty plastic bag in a newly dug grave on an ex-rubbish dump.” The people are Sierra Leone are truly resilient; they have seen more than their fair share of suffering. As if to cruelly remind everyone of this, the raised ground where the relatives stand to watch the safe burials is, itself, a mass burial site from the civil war.

Relatives (wearing blue overshoes) standing on war grave site watching the burials below

Monday, 23 February 2015

The silly things we sign up to...

Fire in the engine?

Luckily we broke down next to this fruit & veg stall
I really apologise for the delay in blogging, in all honesty I’ve found it quite unsettling coming back to Freetown after a pretty intense (but lovely) few days at home. Following my interview, I saw a number of close friends and my brothers in London and my parents and family friends at my mum’s church. I needn’t have worried about stigma. I was really quite overwhelmed with the overall warm reception I received everywhere. It came to the point where I’d never had so many hugs in one day! So I’d like to say a big ‘thank you’ to those of you who I met while I was home.  

Settling back into Freetown has been tricky for a number of reasons. It’s definitely a lot hotter than when I left; no patch of scrubs manages to stay dry even if you’ve been in the unit for half an hour. It’s hot at night too so I’m not sleeping very well. It’s taken me a while to get back into the swing of things and catch-up with emails and meetings I missed etc.

Yet in all honesty the main reason for the delay in blogging is because I did something pretty silly when I was at home and I’ve been debating about whether or not to go ‘public’ about it. I signed up to run the London Marathon. Oh yes, indeed possibly one of the silliest decisions I’ve made in quite a while. With 11 and half weeks to go until the big race on April 26th I thought it would be a really good idea to start marathon training in a chaotic hot dusty pot-holed African city, alongside working in an ebola unit and tons of other commitments. Can you sense my sarcasm?! Aaaaah. My only saving grace is that I’ll be raising money for Kings Sierra Leone Partnership and what better motivation to train hard than working for this fantastic charity and knowing how much the funds raised will benefit the health system in Freetown. I know many of you have been keenly following my blog, thank you so much for your support, if you feel able to contribute to my ridiculous marathon appeal then please visit my fundraising site: I will try to keep you updated of my training progress. 

KSLP vs Isolation Staff Football match


Back to the point of my blog and probably what you are more interested to hear about…

Just before leaving Freetown at the end of January, Connaught Hospital Ebola holding unit was enjoying a relative quiet time. (All doctors will know that you should never say the ‘q’ word as it just jinxes things for later). There were nearly three weeks in a row when the unit did not have a single positive patient identified. There was general optimism in the team and things seemed to be improving all over the country with the daily case number consistently in single figures for the first time in months. The topic of discussion had changed towards how to deal with the low numbers of cases (and high proportions of patients testing negative in holding units) and keep vigilance high to prevent lapses in the screening process and so exposing healthcare workers in the main hospital to potential Ebola suspects. So it was with some frustration that in the first week of my return, I found the holding unit full and a few positive cases identified. We’re not talking big numbers but 1 or 2 positive cases every few days. As I’ve said a few times in this blog, it’s difficult to know what’s happening elsewhere in the city. There are so many different holding units now (which is fab) it just means the burden of the epidemic is spread and although Connaught hospital are only seeing occasional cases, if this replicated across 10 different sites then we still have a significant epidemic. In fact, the national data has shown a fluctuating daily case rate of between 2-12 new infections in Freetown over the last month. Dr Tom (the original ID consultant who trained me) has written an insightful blog entry about how the ‘last mile could be the longest’ in winning this battle and I very much agree with him. We are very far away from having 42 days (two incubation periods) of no cases, which is the current definition of end of the outbreak. Cases are still spread across different areas of Freetown, different districts of Sierra Leone and also the neighbouring countries of Liberia and Guinea… the whole region is so interconnected that each village, town or city really can’t afford to become complacent until all three countries are in the clear.

So it’s going to be a long time yet until we are ready to stop screening all patients that attend the hospital. This means that everyday sick patients who meet the case definition are getting non-specific and often inadequate care in an Ebola holding unit rather than seeing the ‘normal’ doctors in the Accident & Emergency departments. All this in order to protect healthcare workers and trace every last case of Ebola but at what cost to individual’s health? For example, a lady who is currently under investigation for possible Type 2 Diabetes at another health centre, attended our hospital feeling unwell, met our case definition and was admitted to the unit. Over the next two days she deteriorated and sadly died before her Ebola blood result was available. Simple investigations are put on hold due to the risk of Ebola, for example a glucose meter, which would have made the difference in giving this patient some insulin and preventing her likely diabetic coma leading to death. The family also have to come to terms with the fact she will have a ‘safe’ burial as an Ebola suspect – although this, as I discovered yesterday on a visit to the Kingtom Cemetery, is very complicated process and topic for a blog entry of its own.

We had a patient in our unit this week with tetanus. He was isolated for Ebola as the overlap of symptoms can mimic almost anything and yet as time progressed and his clinical condition developed it became more obvious that he had tetanus; recurrent tonic seizures with a classic lock-jaw, arched back and neck extension. He even had a puncture wound on his right foot where the often-deadly spore entered his body. I remember looking after a couple of patients with tetanus during my elective in an Infectious Diseases Unit in a tertiary referral hospital in Senegal. That was in the intensive care where they had oxygen, strong painkillers, and close observation for quick response to seizures. There are many distressing aspects about tetanus, patients remain conscious throughout their muscle contractions and experience a great deal of pain. Within the unit, we were able to initiate antibiotics and whenever a healthcare worker witnessed a seizure, we could administer diazepam and monitor him for respiratory depression. However, there are times when no one is inside the unit and so our care was suboptimal. Once the neurotoxin takes hold, “if patients can be supported through one or two weeks of muscle spasm and other complications, the chances of complete recovery greatly increase” (Current recommendations for treatment of tetanus during humanitarian emergencies, WHO Technical Note, January 2010). Also, the KSLP pharmacist, Suzanne, spent an afternoon trying to procure tetanus immunoglobulin from any pharmacy or hospital (including the private ones) in Freetown but nobody stocked it. Most frustrating of all is the infection is completely preventable with routine childhood vaccinations. The man had a negative Ebola test and has been referred to the hospital for ongoing support.

I mentioned in an earlier blog entry, non-Ebola healthcare, about trying to arrange a system for our negative discharges. This is very much work in progress but some successes have been achieved in the last few weeks. Connaught Hospital, with agreement from the Ministry, now waivers the 15,000 Leone registration fee for all patients who have come through the Ebola holding unit and tested negative and also Ebola survivors from treatment units. There’s now a referral method for reserving a bed in observation unit, even from other holding units across the city. This was essential because on countless occasions ambulances were coming to drop off patients for ongoing medical care when there were no beds available or without informing the patient’s relatives. It’s by setting up systems like this that I think Kings’ can have a real positive and sustainable impact on the functioning and efficiency of the health service.

Sunday, 25 January 2015

How (not) to communicate in an ebola crisis

16th Jan: A few days ago, I received confirmation of my interview in London on the 28th January for Core Medical Training – the next step in my training that will re-start in August. So I’ll be heading home a week on Sunday for 10 days for a break and to coincide with this interview.
On my one (half) day off last week, I started to think about interview preparation and looked to a list of sample questions:
  • Tell me about a time you’ve had to show resilience to achieve a goal.
  • Please describe a time when you were unsure whether what you were being told represented the patient’s true thoughts or feelings. How did you recognise this? What did you do about it?
  • All Doctors need strong communication skills. Can you give me an example of when you have used your communication skills in a difficult situation?
Ha! How am I ever going to talk about anything other than my experience at Connaught Hospital?

Communication in an ebola context – I could write a book about this! Just trying to take an accurate history from a suspect patient in the screening tent has been one of the hardest things I’ve done since leaving medical school. Firstly and most obviously there is a language barrier. Krio is a really cool language. It’s relatively easy to understand maybe 70% of it is actually English in a ‘slang, kind of sloppy accent’ with the odd ‘nah’ and ‘de’ thrown in between words… “Ah da go nah beach” for example. I’m getting quite good at asking a history in Krio, “you de bodi wam?”, “you de vomit?”, and my favourite… “you de toilet fast fast?” But even having mastered the lingo, it’s rare that you get a straight answer. It feels like there are about a hundred and one ways to ask if someone has a fever. They will often completely deny it, “no bodi not de warm, no, I not get no fever… but I get feel fo malaria and I de sweat beaucoup” and the person is obviously sitting there in a thick coat, dripping in sweat and shivering. You check their temperature and it’s 39 deg C.

Communication between colleagues is also tricky mainly because whilst wearing PPE your hearing is all muffled by the suit, your mouth’s covered by a mask and there’s nearly always a background din of arguments, distressed relatives or ambulance sirens nearby. It’s so essential that the team is well organised though and communicating effectively. Especially if it’s a busy morning in the unit with multiple negative patients to discharge and new suspects to admit, ensuring everyone gets the correct name band, bed number and making sure their paperwork all matches up correctly is essential. It also doesn’t help that there are only about 6 different surnames in Sierra Leone; so at times there can be many Kamaras, Sesays, Koromas, or Contehs on the unit along with multiple Fatmatas, Mohammeds and Ibrahims etc. You can see how easily problems arise!

Good communication skills is something that the western-trained doctors and nurses have had drilled into them since day one of their training. It would be easy to blame the ineffectiveness of communication to a simple difference in culture here but I do believe it is something that can be taught and practised and improved upon. The importance of this was no more apparent to me than on Monday when I was called by the doctor working in out-patient department to speak to a relative of someone who had just died. Assuming, incorrectly it turns out, that the doctor, who had assessed the patient when she was alive and witnessed her death in his small office, had told the relative I introduced myself to the husband and added “I’m sorry for your loss”. However his blank bewildered stare made me realise suddenly that no-one had actually told him. So, embarrassingly, I tried to back-track very quickly, took a brief history and broke the bad news (again) hoping he wouldn’t remember the first thing I said. Oh dear, what an example of how not to communicate - maybe not one I should bring up at interview!  Later, I talked directly to the doctor and asked him why he hadn’t told the husband. Looking uncomfortable, he made an awkward remark about how he prefers to avoid talking to relatives about death directly. “It often just makes them too upset, sometimes they can even get angry and aggressive and I don’t like it when the situation gets difficult like that”. This just made me feel unbelievably lucky for the medical training I received and the quality of professional care we have in the UK. This doctor didn’t know any different, he’d never been taught how to effectively talk to patient to elicit what’s going on, how to actively listen to someone’s ideas, concerns or expectations, or have compassion or empathy in informing a man that their loved one has died.

The NHS feels like a galaxy away. I know there are shocking news headlines of busy A&Es and unsociable work hour disputes in the UK right now.  A few weeks ago I would be right in there campaigning for a more just system as well, and of course, I still do support the negotiations for fair junior doctor contracts… and yet here, the debate scales into insignificance. Similar issues crop up, ofcourse, but in Sierra Leone it’s healthcare workers campaigning to get paid in the first place. Since the ebola response scaled up a few months ago, there are some nurses and cleaners in our unit that have still not been paid a penny for the dangerous job they have opted to take on. All ebola healthcare workers should get paid a ‘hazard pay’, which is a monthly financial incentive to work with high-risk ebola patients. A recurrent problem encountered in some of the other hospitals that KSLP supports (and many others, I’m sure) is the list of ‘hazard pay’ ebola staff seems suspiciously large compared to the number of people actually working in the unit.  There are numerous other examples of corruption in the system here, but I’m getting away from the point…

25th Jan: I never managed to post the above blog – got side-tracked/busy with IPC spreadsheets – oh how my Kings colleagues will tell you, “I do love a good spreadsheet!”  I’m currently sat in Casablanca airport on my way home. What will await me? cold weather – it was minus 9 in Amersham a few days ago; culture shock – just the journey home on the tube will feel like a jump in the deep end of technology, functional transport systems and busy, unfriendly people; a welcoming, comforting cup of tea with housemates – definitely.

How about stigma – well maybe? Since I’ve been in Sierra Leone, I’ve heard of countless examples of returning ebola workers facing concerns of friends and family not wanting to see them for fear of contracting ebola. There’s a common theme running through most examples, it’s always in reference to children. I was talking to one Save the Children medic on my flight just now who says he cannot go home to his wife and kids for the next 21 days because his children’s school will not allow them to attend if he sees them for fear of spreading ebola. Similarly, following very honest discussions with my brother, it was also decided that it was probably best I didn’t attend my nephew’s birthday party on Thursday, not because of the risk to his family but the concerns of the other kids’ parents that will be there too. I completely understand where this worry originates. I think the vulnerability of precious, innocent children and our inability to quantify risk appropriately as human beings leads to an emotive sense of overprotection. If the image of a sick, weak and confused patient vomiting blood doesn’t warp one’s sense of risk then I’m not sure what will.  Over the next 10 days I’m just going to have to remind myself of how I felt back at the end of November when I impulsively washed my hands after meeting a co-worker from Kings. Sometimes fears are irrational and there’s nothing we can about that. Let’s just hope I avoid getting the 'flu (and a fever that gets confused for ebola) so that I can actually attend my interview on Thursday!

Monday, 19 January 2015

Non-ebola health services

Our small (piece of the pie) holding unit has been half empty most of the week. Of those isolated patients only a handful have been confirmed positive.  Obviously if this is a trend that is reflected across the district/country then it is really encouraging. However, what it has done is expose the vast shortcomings of the general non-ebola healthcare system that is left behind, neglected in the past few months but also chronically under-resourced for years.

Some of the suspected patients who test negative are sent home but many require ongoing medical care. Obviously they arrived unwell and it’s understandable that our generic one-size-fits-all 24 hours of antibiotics and anti-malarials hasn’t cured them. So we often refer patients to the observation department (which is the equivalent of a short-stay acute medical ward) from where they can be admitted to the wards. Registration to see a doctor costs 15,000 Leone (£2) and admission costs 30,000. Patients, or relatives, have to pay for all investigations, blood tests, medicines, even equipment – such as IV giving sets, canulas, catheters and catheter bags (the latter two cost 16,000 Leone (£2.15), surprisingly cheap - I thought!). This payment system was set up from structural adjustment programmes by the World Bank in the 1980’s. A relative or caregiver has to stay with the patient at all times to help with general care of the patient – bathing them, taking them to the toilet, providing food, whilst the nurses do drug rounds, take observations, change dressings etc. In many ways this system works quite well because individuals are often very well supported by family members. It’s only when homeless or ‘destitute’ patients are unwell and need admission that the true limits of such a privatised health service are revealed. There is certainly no social welfare system here.

There are a number of reasons why our negative patients are not particularly welcomed on the wards; 
  • Stigma – suspicion that being inside the unit has caused cross-contamination and/or possibly a general distrust in the lab results
  • Jumping the queue, every day there are lots of patients that need to be admitted from A&E through Observation Ward, but our negative discharges get priority so that they free up isolation beds in the holding unit. There’s no A&E overnight either so there are often queues of patients in the morning waiting to be screened and see a doctor. (I actually think this is a good sign as it shows that people’s faith in the system is improving as they recognise that non-ebola healthcare is getting back up and running compared to a few months ago.)
  •  No caregiver or relative – we always try to contact the relatives when our patients are discharged but sometimes it proves so difficult to get in touch with them. Incorrect contact details on the form, mobile phone network issues, etc. meaning there’s often quite a delay in them arriving to care for their sick relatives
  •  Financial - relatives not wanting to pay or not being able to afford to pay registration or admission fees.

Also, as a consequence of quarantine homes, community surveillance and general awareness unwell individuals are being round up and tested for ebola much sooner than they probably would present to hospital before the epidemic. When ebola is ruled out there is an assumption that they should see the doctor, they are in a hospital after all, resulting in an overwhelmed and struggling general non-ebola medical system.

The front of the hospital: screening on the left, holding tent for
 suspect cases on the right

KSLP are very much involved with trying to get the health system back up and running. One of my roles over the last few weeks has been to do the ground-work for a large Infection Prevention & Control (IPC) United States funded 1-year programme in four different hospitals,  including Connaught Hospital, that KSLP will be supporting. The grant will support 18 different government hospitals in total and includes setting up a Patient Safety Committee in each hospital, training all healthcare workers in IPC and infrastructure improvements in Water, Sanitation & Hygiene (WASH). It’s a very necessary programme as the concepts of hand washing, infection prevention, safe sharps practices, appropriate antibiotic therapy etc are all quite novel here but it will be good to build on the initial understanding that ebola has generated. Hopefully, it will help hospitals stay open and healthcare workers stay safe as ebola ebbs away (but flares up occasionally) over the coming months.  Personally, I’ve been learning all sorts of new skills – how to scale up costs, the interaction and co-ordination of large organisations all wanting to do the same thing, engaging local leaders of hospitals in programme design and implementation and even the difference between a septic tank and a soak away!

Brendan & Nat admiring the view of Kroo Bay from the hospital waste management site
It’s also been quite satisfying to get my medical brain back in action in the last week or so whilst doing my clinical duties. (I do apologise to my non-medic blog readers for this paragraph…) We have had a number of patients in our screening tent that meet the case definition (fever plus 2 other symptoms) but quite obviously have other diagnoses than ebola. The only difficulty is we have to isolate them before anyone on the general wards would go near them for fear of healthcare worker infections – a decision that is entirely appropriate but frustrating as it limits our ability to give good quality care. Last week I trained one of our new volunteers, Brendan, who is an infectious diseases consultant in Wales in how our unit works and how to wear PPE. (It doesn’t feel that long ago since Dr Tom was training me!) It has been great to be on duty with him because he’s helping me spot-diagnose all the other non-ebola medical problems. For example, a thin, malnourished older woman with extensive cervical lymphadenopathy and parotitis (HIV/AIDS?), progressive peripheral neuropathy and neck pain in a teenager (Spinal TB?), a young woman with a stiff neck, altered personality, left-sided limb weakness, and left-sided hemianopia over a few months (HIV – Progressive Multifocal Leucoencephalopathy?). All these patients were negative for ebola but unfortunately I have not managed to follow them up to find out confirmation of the diagnosis – assuming they had the money to pay for investigations.

A particular case that has resonated with me this week is a little boy who had been kicked in the left side of his abdomen when playing with some friends at the weekend. His parents brought him in saying that he’s complaining of abdominal pain, loss of appetite, weakness and possibly some fevers over the last two days since the scuffle with his mates.  He was doubled over in pain, breathing fast, with a grossly swollen firm abdomen. I immediately wondered if this boy had ruptured his spleen. He definitely didn’t look like he had ebola but all we could do was isolate him (he officially met the case-definition) and give him conservative management until his test came back negative. We spoke to the surgeon on-call (hurray - even the surgeons have come back to work recently!) and he confirmed our suspicions that they would not operate unless he had a negative ebola test. So we admitted the little boy, away from his family, into his own room (so as to minimise cross-contamination). We gave him fluids, IV antibiotics and painkillers. I’ve never seen an adult, let alone a child, cope with such obvious pain with incredible resilience; he didn’t even seem too fazed to see me in PPE. The next day, his test unsurprisingly came back negative and we were able to transfer him to the wards. In the end he got transferred to a different hospital for a possible splenectomy (removal of spleen) so again, I don’t actually know anything of his progress.

A sweaty post-PPE pic!

Just a quick mention of other non-ebola health problems before I finish this mammoth blog entry! There was a general announcement via various NGOs/hospitals this week to look out for cases of measles as the children’s hospital had seen a couple of suspected cases. With childhood immunisation rates down by 40-60% in some peripheral health units over the last few months, the population has lost its critical herd immunity and are setting themselves up for significant outbreaks. Not something we want to complicate the post-ebola transition particularly.

The other obvious critical shortcoming of the non-ebola health care in the last few months is the continuity of HIV/TB services. As most hospitals were pretty much shut for the entire months of September to December, and some still are closed, many HIV and TB patients were unable to attend their routine out-patient appointments. Many have presumably stopped their medications leading to the risk of developing resistant strains. UNAIDS estimates that 1.6% of Sierra Leone is living with HIV in 2013 – although it’s not clear from the UN report I’ve just read how this is calculated. HIV patients are obviously more over-represented in hospital settings than the general population but I have definitely seen signs of disseminated AIDS in many patients. I would love to try and quantify the difference in service provision before, during and after ebola  though I suspect that may be rather difficult!

Sunday, 11 January 2015

Ebola Myths

I thought I would share a few myths about ebola that I’ve heard about since being here… thanks to Ibby (Fixer), William, Patricia (nurses), housemate Katie and night nurse Tamba for helping me compile this little list:

1) Initially nobody thought that ebola was real. Everyone thought the government was making it up so that they could invite more NGOs, agencies and funding into the country and make hefty profits for themselves.

2) Quote: “A witch-craft was flying over the provinces and crashed into Port Loko (a large town) causing a lot of deaths all of a sudden.” I don’t even know what to make of this - is it a bird? is it a UFO? No, it's a witch-craft! In fact, of course, these deaths were actually due to ebola but the local people’s strong traditional beliefs were the only thing that could explain such a catastrophe. Lots of people in West Africa seek traditional healers (‘herbalists’) before attending formalised medical care. One thing the local nurses here pointed out is that this means literally hundreds of the traditional healers have died from ebola during this epidemic.  Practices and knowledge are passed down by elder generations within families so this loss will surely impact the availability of traditional healers in the future, especially in the provinces. Although the nurses seem to think that this will not diminish people beliefs. Currently we are seeing a hotspot of cases in Waterloo, a suburb of Freetown, where there is a strong dependency on traditional healers.

3) All the patients that were taken to the hospitals were found to be ‘positive’, in contrast to those who were sick and died at home.  So began the association with white doctors working in facilities and confirming ebola cases which was mis-understood as white doctors giving people (i.e. injecting) ebola. This spread a deep mistrust amongst the community and increased the fear of attending hospitals.

4) In August, a well renowned pastor from Nigeria had a vision that if all people bathed in hot water and salt before daybreak they would be protected from catching ebola forever. Apparently, it was attributed to a quote from the bible about being cleansed of sin by washing in salt water. The message was spread quickly across the country; bellowed out from all the radio stations, repeated at church services, loud-speakers, whatsapp messages – you name it… resulting in the whole country wanting to get their hands on some salt. Will told me that in Kenema people turned up at the treatment centres with huge kilo packets of salt to ‘cure’ the patients. In fact, just last weekend, I came across remnants of this rumour myself. Amar (a Kings colleague) and I were at the beach for the day and we took a boat trip up river to a small waterfall with a man called ‘Heavy D’. He proudly told us that there was no ebola in his village “because we live by the sea”. Obviously I questioned him on this, trying to warn him that was not the reason and he still needed to take precautions if anyone became sick, when Amar pitched in to explain his thinking was related to the salt-water message from August. I find it so worrying how inaccurate information can cause such long-lasting false beliefs. It reminded me of the crazy rumour in Zimbabwe and South of Africa that “having sex with a virgin cures AIDS”.

5) A (almost) funny and verging on ridiculous rumour I heard yesterday was about how Medecin sans Frontieres are screening for ebola at their isolation units. Just as background, our screening process involves asking every patient that attends the hospital whether they have a fever, or history of fever, in the last 3 weeks – if yes: they are asked a whole list of symptoms (vomiting, diarrhoea, weakness, abdo pain etc), if no: they are asked if they have any contact history with sick people, dead bodies, burials etc. In contrast, night nurse Tamba told me his friend works for MSF in Freetown and their screening process is completely different. According to Tamba’s friend, they give a suspect patient a peanut and wait 5 minutes. If he vomits then he probably has ebola and is isolated. If he doesn’t vomit he’s probably fine and allowed home! I tried exposing the absurdity of this screening process to Tamba,“do all patients with ebola vomit?” No! Even so, he still believed his friend and not me.

And so the rumours continue…

Wednesday, 7 January 2015

End of the middle?

Sorry for the delay in posting my next blog. I’ve been getting wrapped up in all sort of things but actually mostly non-ebola work and starting to think about the post-ebola transition... I'm not sure I've got the balance of writing blog entries vs working in the unit quite right yet.

So I stand corrected… maybe ‘The Surge’ is making a difference. In the last couple of weeks there has definitely been an increase in the number of holding beds (in isolation units where ebola suspects are taken) available. Many of the beds are being filled with suspects rounded up by the community teams who are going door to door looking for sick people in confirmed ebola hotspots of the city. There were some initial suspicions that the community teams were just isolating the elderly, the infirm and the homeless but if this was the case then the proportion of suspects testing negative would have increased and that, as far as I am aware, hasn’t occurred. In fact, in eastern parts of the city, which is generally more crowded and poorer and consequentially more ebola-ridden, the proportion of suspects testing positive is about 50% - higher than in most areas. These diseases are always the same – Paul Farmer wrote a compelling diary entry back in October about structural violence and health inequality relating to ebola.

Even the scale-up in laboratory testing is filtering down to real improvements on the ground.  We now have three collection times for blood tests in a day from Connaught’s Isolation Unit: 8:30am, 12:30pm and 4:30pm. Yesterday, we had patients admitted in the morning whose bloods were sent by 12:30pm and amazingly the results were back by 7pm. This meant we were able to discharge four negative patients home in the evening without them having to stay any longer in our unit, minimising their exposure to possible positive patients.  It also meant we could isolate the two remaining suspects in the holding tent rather than sending them home to the community. What a win-win situation J
So it looks like things are starting to turn around; maybe this is the beginning of the end or more likely the end of the middle. What happens next in looking to the post ebola phase of health system strengthening will be the subject of another blog entry. It certainly was and continues to be the focus of the Kings Sierra Leone Partnership to make long-term positive impact on the structure and quality of the health system and I’m excited to get involved in a few projects that have a longer outlook and non-ebola focus.

A little disclaimer – it’s very hard to get accurate information about how the epidemic is progressing here. I suppose I am at an advantage about not having the media cloud my perspective but the above assessment is simply based upon discussions with colleagues and a general feeling within the team rather than facts and figures that I have personally have opportunity to see.