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!

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