Final days

I am now in my final few days in Sierra Leone, beginning to pack up and make that mental and emotional transfer that always slightly pre-empts the physical transfer. The beginnings of the excitement about seeing the people I have missed, eating the foods I have craved, and other aspects of life at home. And also a creeping sadness as the realisation grows that my time here is coming to an end.

I feel incredibly lucky to have been able to come out to Sierra Leone this time. When my initial plans to come out to Sierra Leone for 6 weeks to work in an Ebola treatment centre fell through, I was very disappointed. I had been so looking forward to being back here, and hoping that I would be able to make some kind of contribution to this country that I fell in love with last year, during this particularly difficult time. But as with any disappointment, what I had not counted on was the incredible opportunity it gave me, by allowing me to apply and be given this short term position with Welbodi.

It has been a fascinating time to be in Sierra Leone, for many of the reasons I have blogged about before. Probably the most interesting for me has been witnessing the beginnings of a transition phase of emergency aid and humanitarian work towards thinking about the longer term. At all levels, people are thinking and talking about this transition – at the government and ministry levels, in NGOs of all sizes, and at a local community level too. The “what happens now?” question. Organisations and groups that were active here before the outbreak beginning to go back to their routine activities, and examining whether they are what they still want to be doing; and organisations that have come to Sierra Leone for the first time, as many have, wondering if they might still have a role to play over the coming months and years.

I have to admit that it makes me feel slightly anxious, thinking about this transition. There is so much energy and momentum, and yes, money, coming into the country at the moment, and there are many organisations that only started forming their relationships with Sierra Leone during this crisis period that I am nervous that there might be a bit of a bulldozer mentality in some places: we’re here now, let’s start some projects- without real involvement and participation of the existing structures such as the District Health Management Teams. It comes from a good place, people wanting to help, and hopefully my anxieties are unfounded, but I do worry about the risk of bitty, uncoordinated and top-down approaches developing, which could have the potential do more harm than good. There is the potential to do a lot of good as well though, and to help this country build itself a stronger health system, and maybe it is the risk of some of this potential being wasted that makes me feel anxious about it.

For me, working with Welbodi has been very rewarding. It is an organisation that not only states intentions of capacity building with a participatory approach, but practices it too, and has been an inspiration to me about how long term health development work can and should be achieved. By establishing a long-term relationship with a government hospital and helping them to achieve their own goals of development with expertise, funding and support, the changes that are made are sustainable and meaningful.

So in all, I have been very lucky to have this opportunity, and it has allowed me to fall even further in love with this country. Leaving on Sunday morning, I know that my heart will be heavy, but I also know that I will not be saying goodbye to Sweet Salone, but just “until the next time”.

Campaign to Zero!

This was written over the weekend, but this is the first time I’ve had enough internet to post it. 

Freetown has a strange atmosphere today. From this morning at 6am until 6pm Sunday evening, the streets are going to be unnaturally quiet as everyone in the city has been told to stay in their homes. This is the second such campaign in Sierra Leone, and this time is called the Zero Ebola campaign, a bid to wipe out the last of the Ebola transmission that is still active in Freetown and a few other districts in Sierra Leone. The number of cases of Ebola in Sierra Leone dropped precipitously earlier this year, but since then has plateaued with ongoing low levels of transmission continuing every week.

Three main strategies are used to control the outbreak: early isolation of cases, so that they do not go on to infect other people, safe burials, and contact tracing, and only when all three of these pillars are fully adhered to will the disease be eradicated. For every patient who is diagnosed with Ebola, information is collected on everyone they may have come into contact with since they became symptomatic. These people are then followed-up for the next 21 days by dedicated Contact Tracers, and anyone who becomes unwell is brought by ambulance to a health centre for a test.  This can be challenging, both in rural districts where contacts may be in very remote areas, and also in urban areas such as Freetown where people live in very close quarters. Currently there are still patients being diagnosed who are not known contacts, suggesting that there are still more cases that are not known about, out in the community.

During this Zero Ebola campaign, teams will be coming door-to-door doing continuing education of communities. I imagine that there will be very few for whom information will be new – the message of Ebola transmission avoidance is everywhere – but hopefully it will be serving the purpose of reminding people that this is not yet over. People are tired of talking and thinking about Ebola. They want desperately to move on with their lives, which is so very understandable, but unfortunately it is not yet time to relax.  The other purpose of the campaign is for teams to actively look for any people who are unwell and encourage them to come to health facilities for Ebola testing.

So for now we sit in our flat, and we hope that the campaign is successful. The past few days in Freetown have felt a bit mad. Everyone stocking up on their supplies for the weekend – in a context where few people have access to fridges, people buy their food from day to day normally. People coming into Freetown for the weekend, people leaving Freetown to spend it with their families in other districts, traffic even more hectic than normal and plenty of people not turning up to work, in order to “prepare”. And now, I imagine, central Freetown must feel even more mad. Of course, I can’t witness it, I am hunkered down in my flat for the next 3 days, but the idea of the crazy-chockablock Freetown roads devoid of vehicles is certainly a foreign one!

I hope it will have the desired effect of further pushing down the rate of transmission. We have seen by the progress that has happened already that the interventions we have can work. And in the meantime I will satisfy myself with an enforced three-day weekend, reading, snoozing, and reflecting on my time here, as it draws to a close in just over a week.

A smattering of hospital politics

Sorry folks, it’s been a while. But I’m back!  In this post I want to focus on a bit of the minutiae of what I’ve been working on to give a bit of an example of some of the challenges faced by healthcare staff here.

As I’ve said before my role here is as an Infection Prevention and Control (IPC) Mentor, working in a team with some senior Sierra Leonean nurses in 2 hospitals in Freetown. Together we are hoping to improve IPC practices in the hospitals both through training and also through improving systems and infrastructure.  It’s pretty clear that if you teach people to wash their hands and wear gloves, but then provide them a working environment with neither the facility to wash their hands nor gloves to wear, that is not going to happen. Likewise, providing the facilities but not the training is an equally dead end. This past week we have all been attending train-the-trainers training along with 2-3 senior nurses from all the other government hospitals in the country, and like them will be rolling out what we have learnt to the facilities we are working in. The course was designed by CDC and ICAN (Infection Control Africa Network) and was based on the material that we piloted a couple of weeks ago with the staff at the Children’s Hospital, Ola During. Here are a couple of photos I took at the training (permission given by participants photographed):

One participant demonstrating use of PPE

Me with Sister Sai who I worked with in Kambia last year, and who attended the training to take back to Kambia

One of the first structural issues that I have been tackling in the past couple of weeks is supply of basic PPE items such as gloves and aprons to wards in one of the hospitals. Spending a little time on the wards made it clear that on some wards staff are running out of stock in between their weekly supplies, and are not always able to replenish their stock in a timely way.  This leaves them the dilemma of whether to treat patients whilst unable to properly protect themselves, or to leave patients in need of care alone – a decision that no healthcare worker should have to make.

Delving into this issue a bit deeper demonstrated to me that there is certainly not just one reason that this is happening.  As I understand it, the normal process is that the nurse in charge of each ward fills out a requisition form at the beginning of the week of all the stock that the ward will need. This is then given to Matron who approves or otherwise the list, and then it is handed on to the pharmacist who does another check of the list, and then informs the storekeeper of the stock that should be taken from the store.  Between the pharmacist and the storekeeper they keep track of how much stock they have on the premises, and are responsible for ordering further supplies from central medical stores. If central medical stores are out of supply of any essential stock, then the Medical Superintendent, who is the doctor in charge of the hospital, has to release funds for purchase of this stock from another source.

The issues in stock supply can and do come from any of those stages.  Firstly, I am not sure how much training on stock level estimation and ordering many of the ward sisters have had, so I wonder whether their predictions for what they will need for the week are accurate or not. Secondly there is an issue, real or imagined to varying extents, of stock being taken home by staff, so nurses in-charge have been known to lock it up, only for use when they are there, so they can keep an eye on it. Then if stocks run out during night shifts for example, there is then no way for the junior nurses to access it. In turn, the pharmacy staff don’t want to be giving out too much stock at a time, as they feel that it may not be used solely in the hospital, and then finally central medical stores can easily run out of basic equipment, adding a delay to any equipment ordering.

Our first step has been to arrange meetings between the nurses in charge, matron and the pharmacy so that they can discuss some of these issues. This seems like a ridiculously simple solution, and it isn’t the be all and end all, but starting a dialogue does seem to have had some influence on stock levels on the wards. Where it goes from here, we’ll see. Every aspect of setting up a well-functioning IPC programme in a hospital is likely to have this many aspects or more to unravel, and will be a complex job. I’m only here for a few more weeks, so will not be here to see much of it come to fruition unfortunately but the main actors in this programme are national staff, in a much better position to make lasting change than I am, and in the meantime I’ll do what I can to contribute!

A little reflection about sustainability

A couple of weeks in and I’m thinking a lot about the way that the international community has responded to the Ebola outbreak, and what that will mean for the future of Sierra Leone. It’s widely acknowledged that the international response was slow to respond to the crisis, leaving a country that was ill-equipped to deal with this kind of situation to manage alone. The stories from the early days are horrendous. Families left with dead bodies in their homes for days in 35 degree heat as there were not enough retrieval teams to collect them to bury them safely. Ebola Treatment Centres (ETCs) having to turn people away and back into their communities as they had no more beds. Entire families wiped out as people’s loved ones became dangerous viral hazards within their homes, when stroking your dying child’s hair becomes a death sentence.
But then, thankfully and gratefully received, the international community did respond and in a big way, with very significant amounts of money and manpower. Large treatment centres were erected throughout the country with world class laboratories, an Ebola ambulance service was made functional, and thousands of people nationally and internationally volunteered to work in Ebola Treatment Centres in the gruelling heat and heart-breaking conditions. Finally people started getting what was needed.

Now we are a stage when case numbers are decreasing, many treatment centres are standing nearly empty, and there are plans to begin to close them, one by one. We are at a stage currently when, bizarrely, Ebola is one of the only conditions that you can guarantee getting treatment for. The resources have been committed and the facilities are there. Meanwhile, what happens if you have a different diagnosis? What if it’s malaria, or typhoid, or tuberculosis? What if it’s a complication of childbirth? It can be much harder to access care for these problems – many people are too afraid to go to hospital at all at the moment, and if they do they may have to await a negative Ebola test before being able to access care.
Many clinics and hospitals have closed at some point during the outbreak, with very understandable and real concerns about the health of their staff. This has led to a surprising example of inequity – you can now perhaps receive better care for Ebola than for other, less feared, conditions. Some ETCs in particular are providing quite advanced care and using tests that are for the most part not available in the rest of Sierra Leone, such as blood electrolyte levels (a very routine and basic test that is performed very frequently in high income settings).

Yes, absolutely, this kind of massive vertical programme was needed to deal with Ebola. Without it I cannot bear to think about what kind of situation may have arisen. But the question to my mind is what happens next – what is the next stage?
A couple of days ago I had the opportunity to be shown around Princess Christian Maternity Hospital, which is one of the hospitals I will be focussing on while I am here. I have a certain amount of experience in Sierra Leonean health care settings now, having worked in Kambia for 5 months last year, so while I don’t think I was feeling complacent, I didn’t expect to be shocked by the conditions that I saw; but I was. It was evident that support is still needed to enable the staff to access running water and supply a fresh and clean set of linen and mosquito nets for each patient, and dispose of their waste safely.
None of this is different or worse from what I’ve seen before, so I was a bit surprised at my reaction. But I think it stemmed from two things – firstly, this hospital is much bigger than Kambia Government Hospital, so all the challenges seem bigger and harder to surmount in some ways. But secondly, and more importantly, because it is astonishing to me that now, even now, in the context of the biggest outbreak of Ebola ever seen that has infected over 400 health workers in Sierra Leone alone, and despite the millions and millions of dollars that are flowing into the country to tackle this, even now most health workers cannot even wash their hands between patients. To me that is extraordinary and it’s unacceptable. It is brought home even more by the “in loving memory” posters stuck on the hospital walls in tribute to colleagues, some of whom have been lost to Ebola in the line of duty.

It is an absolute testament to the courage and resilience of the healthcare workers here that they are still working at all. I’m not sure that I would, knowing that I was putting myself in danger every day, and being unable to protect myself as soap and water are not always available. This is not just about Ebola, although that of course is important and mustn’t be forgotten, it is about all the other infections that exist and that are inevitably passed around between patients and staff when people are not able to protect themselves.
In some ways the emergency stage is the easy stage. There is no time for lengthy consultation and compromise, it is accepted that international agencies have the right and indeed the duty to act swiftly and almost unilaterally. That is not to diminish the efforts that have gone in to trying to control this outbreak, they have certainly been life-saving, and the work from individuals has been relentless and difficult. But the next stage, surely, is to help support a health system that, weak from the outset, has been utterly ravaged by this crisis – health care workers have lost their lives, routine vaccinations have not been given, HIV medications have been hard to come by, and hospital staff are too afraid to come to work. It is to strengthen the health system so that this can never happen in the same way again. And that will not be by imposing grand solutions from on high, but by working painstakingly and meticulously at engaging every level, from Ministry to hospital cleaner, in every aspect of the healthcare system, listening to the people who work there and making a solution that is owned by the people to whom it matters most. There, the hard work really begins.

Infection prevention… same old same old, or something new?

Time for a bit more about what I’m actually doing I think. It’s been a fascinating week, an insight into development work that I have never had before. The Infection Prevention and Control (IPC) project that I’m working on has been designed by the Ministry of Health with input from WHO and a large number of NGOs including the Welbodi Partnership who I am working with, as well as the CDC who are funding the project. The CDC (Centre for Disease Control) is the US state department dealing on health protection and outbreaks in the states and globally – quite a big deal in this world. The idea is to enable Sierra Leonean health workers to work safely in the current environment and ongoing. At the moment any person entering a hospital is screened for Ebola. This means that they have their temperature checked, and are asked a series of questions about any symptoms they might have and any contact they may have had with people known to have Ebola. If they meet certain criteria they are placed in the Isolation Unit to await an Ebola blood test, and if not they are admitted onto the ward. There is still a chance however that that patient is still incubating Ebola when they are admitted onto a general ward and will become positive during their admission. There is also a chance that the patient has not fully disclosed their symptoms, as the case definition is widely known in Sierra Leone, and understandably, people are scared of being admitted onto an Ebola Isolation Ward. Therefore people may adjust their version of events to avoid meeting the case definition. Because of these factors, medical staff need to be very cautious when dealing with any patient on the ward, as it may be difficult to know whether or not they are infected. This is one reason that teaching staff how to protect themselves is so important at this time. And by enabling staff to protect themselves, they are then able to protect their patients, and protect their communities.

The topics that we are focussing on are as simple as good hand hygiene techniques, waste segregation so that medical waste, general waste, and sharp waste (eg needles) are disposed of separately, and use of personal protective equipment such as gloves and aprons whilst doing clinical tasks to avoid exposure to body fluids.
This has all come to the forefront of agenda and policy because of Ebola, but it is incredibly important in any healthcare setting in any context. IPC is built into how we are trained as healthcare staff in the UK, quite rightly, but in Sierra Leone until Ebola arrived it was nobody’s priority and few staff had had any training at all on how to protect themselves. It is being introduced as a new concept in the wake of Ebola, but it is also an opportunity to introduce understanding of a topic that is very important in any healthcare context.

This week, we have been piloting a training programme at Ola During Hospital for healthcare workers and also other staff such as cleaners, porters, and mortuary staff on IPC. The training programme has been created by the CDC for the SL government with the input of various local partners. Based on the response and feedback we get on the programme this week, it will be adapted and in the next few weeks hopefully rolled out around the entire country. The idea is to allocate a local IPC lead at each hospital who will have the responsibility for IPC in their facility. They will be trained using this programme and then cascade that teaching through their hospitals so that in theory large proportions of people working in these facilities receive training.
Talking about IPC in the UK tends to provoke a rolling of eyes and a sigh – the idea being that infection control nurses are the ones always nagging us to wear the right colour of apron for the right procedure, or telling us things we think we already know about hand washing. Talking about infection control has quite a different impact here in Sierra Leone at the moment. The staff we are training have all lost colleagues to this disease, and they know that this is something that most likely could have been prevented by good practice of IPC methods. It is very real to them that the skills they are learning are potentially life-saving, and they are hungry for the knowledge because of that. That is a powerful, and almost daunting, perspective to be teaching from.

I’m not completely sure what the next few weeks will bring, but I’m looking forward to them and will keep you posted.

Changing plans!

OK, so things have changed a bit since my first post. For various reasons my post with Doctors of the World fell through at very late notice so I did not end up travelling with them last week. Apparently such events are not uncommon in the world of humanitarian aid, but all the same felt quite disappointing to me when I was told. Intent on using the time I had off effectively to contribute to the efforts against Ebola and its effects however, I contacted various other Sierra Leone-based organisations, and was absolutely delighted when I was told by the Welbodi Partnership that in fact they were urgently recruiting and my previous experience in Sierra Leone would make me a potential candidate. YES! Less than a week after my initial email to them I was on a plane to Freetown, and that is where I am writing this blogpost.

It feels so wonderful to be back in Freetown. The sights, the sounds, even the smells! The last time I was in the city was before the outbreak had arrived here, and there are some notable transformations in that time. Every poster, every piece of wall in the city is emblazoned with Ebola-related messages. It’s clear that everything else has ground to a halt in the past year. Another difference is that people have stopped shaking hands – the Salonean culture is a very tactile one, but the message of avoiding body contact wherever you can has certainly been heard. It feels very strange to meet people for the first time and not shake their hand. I feel like a shy teenager without the confidence to greet people properly!

I managed to get to one of the wonderful Sierra Leonean beaches yesterday, but today work began in earnest. The Welbodi Partnership is an organisation that has been based in Freetown for some time, and has aims of capacity building and training mainly within the Freetown children’s hospital, Ola During. The work that I am doing with them is to do with the post-emergency phase of the Ebola response. There is a very real concern about health worker safety over the coming months as hospitals will hopefully begin start providing care again, but it will be some time before Ebola is eliminated completely. The risk of complacency and rebound infections is therefore significant.  The project I am involved with is part of a national programme in Infection Prevention and Control (IPC) training that is due to be rolled out over the coming months that has been designed by the WHO and CDC, with plenty of local input as well. Welbodi are responsible the project in 3 Freetown hospitals – Ola During, a maternity hospital, and a general hospital. It is this project that I am going to be involved with over the next 2 months.  The aim of the project is to give health workers the skills, and just as importantly, the infrastructure to be able to work safely in those conditions.

Today was my first day, so a lot of finding my feet. I was shown around the hospital, which seems huge when I compare it to the small district hospital I worked in in Kambia. I was impressed by how much of the hospital was functioning – much of the country’s health system has completely stopped, but there were patients in every ward and nurses attending to them. There is also an Ebola Holding Centre at the hospital. This is a ward where people suspected of having Ebola are admitted until they get a lab test result; thereafter depending on the result, they are either transferred to an Ebola Treatment Centre (ETC) or into a ward in the main hospital. As patients arrive at the hospital for whatever reason, be it that they are unwell, that they are expecting routine vaccinations, or any other reason, they go through a screening process. Each has their temperature taken and a brief history taken by health workers standing 2 metres away. If they have a fever and a history compatible with a diagnosis with Ebola they are taken into the suspect area, where they will have to wait for a test result; otherwise they are allowed to pass through into the hospital. In the past week they have had only 2 positive Ebola cases to my knowledge, so numbers certainly seem to be on the downwards trend here.

All in all, I feel like this is a fascinating time to be involved in the response and I am really excited about seeing how things progress over the coming weeks and months.

Before the off…

Welcome to my blog! As some of you reading this will know, and some will not, I am due to depart to Sierra Leone on 4^th February to work as a doctor for 6 weeks in an Ebola Treatment Centre in Moyamba, with Doctors of the World. I have promised a blog to a few people who were interested to hear about my experiences and thoughts, and so here it is. I tend to find writing quite therapeutic and cathartic too, so please excuse me if this morphs into a dear diary entry at times over the next few weeks.

Almost exactly a year ago – the first week of February 2014 – I flew into Freetown, Sierra Leone, for the first time. I was going to volunteer with an organisation called the Kambia Appeal, based in the district of Kambia in Northern Sierra Leone, trying to support a local government hospital with clinical support, teaching, and quality improvement projects. At that time nobody had any idea what the following 12 months would bring. I enjoyed the work there a lot, Sierra Leone is a wonderful country full of wonderful people, but it was certainly challenging. The country is among the bottom of the list in terms of the UN Human Development Index (177 of 185 countries in 2012) and the level of poverty is harsh and widespread. Amazing progress had been made in the 10 years since the civil war that had previously ravaged the country, but health services and infrastructure were extremely basic even so. And the tragedy of that is, of course, that what makes a country so much more vulnerable to experiencing epidemics like this (crowded conditions, lack of running water and sanitation etc), is also that this is where the disease will do the most harm because people have so little reserve, physically and financially.

The Ebola crisis in West Africa has been horrendous. It is horrendous. Latest WHO figures as of yesterday suggest that there have been nearly 22,000 cases within Liberia, Guinea and Sierra Leone combined, and nearly 9000 deaths. This has been in a year. Things seem to be improving, but more slowly in Sierra Leone than the other two main affected countries and it is also important to remember that blanket figures mask huge variations between and within different regions. There is also a risk now that figures do seem to be improving of complacency, risk taking, and further spikes in disease activity. And while the rate of new infections seems not to be as rapid as it has been, new infections there are still, and so certainly the need is still great.

An outbreak like this does not limit itself to the physical effects of Ebola. With people understandably afraid to visit the hospitals that are still open, they are not receiving medical help for other treatable problems, such as malaria, diarrhoeal illnesses, and complications of pregnancy, so people are dying of these when a year ago they would not have. Nor does the outbreak limit itself to affecting health – schools, colleges and universities are closed, leaving a year’s gap in children’s education. Many markets are closed to avoid close contact with people, so food is hard to come by. Roads are closed, so even trade outside of markets is difficult.

The response I have had when telling people of my plans to return to Sierra Leone have been quite polarised. Some people are horrified by the idea – why on earth would you want to do that?! – whilst others have seemed excited for me, even envious. People from both camps have been interested to find out about my motives for going.

I became a doctor initially as a route to be able to provide direct help to people with significant need, particularly in low income settings. That is still important to me, very much so, although the more I see and the more I think, the more complicated it seems, and the more difficult it is to know the best way to help. Trying to introduce new ideas and sustainable change in other countries whilst being aware of the risk of paternalism, and trying to help support a system without undermining it – these are tricky issues, and have no easy answers. This particular situation however feels like something I could actually help with. The principles of dealing with this outbreak are relatively simple, and because of my work in Sierra Leone before, I do at least understand a bit about how the health system works and speak a little Krio, the local language.

I also feel loyal to Sierra Leone. I heard about the first cases of Ebola in Guinea last March, whilst living and working in Sierra Leone. I was there as people around me became aware of it, as it made slow but constant progress through Guinea, and then crossed the border to Sierra Leone. Our colleagues at the hospital were scared, and understandably. The hospital we worked at was basic. There was no running water on some wards, gloves were rationed to about 20 pairs of gloves per ward per week. This is not an environment in which it is easy to stay safe from any disease, and certainly not from Ebola. The organisation I worked for pulled out volunteers when the first case of Ebola came to Kambia – a difficult but understandable move (see Josieinkambia.wordpress.com for more in depth thought about it!) – and it was hard to leave colleagues to face this alone while we were whisked to European safety. I suppose part of my wanting to go back is to feel less like I’ve let down my former colleagues.

And so here I am, one day before departing for my training, and how do I feel? Nervous, definitely. Nervous about the nature of the work, the physical endurance of wearing protective suits in that climate (I could barely cope wearing scrubs last year!); the emotional toll of having such an inadequate medical solution to the disease. Nervous that I won’t be up to the challenge, in whatever way that may be. Nervous about life out there – the centre I’m working in is set in a compound, and I don’t anticipate that I will have much opportunity to leave the compound for the 6 weeks I’ll be there. And I suppose, a little nervous about getting Ebola. The personal protective equipment (PPE ie space suits) is good, and there are good systems for making sure it is used properly making the risk very low, but people are fallible, and it could only take one mistake.

But I’m excited too. I’m really excited to be going back to such an incredible country, where beautiful colourful fabrics lie drying in the sun against the red of the dirt roads, the pineapples are sweet and juicy, and singing and dancing seems like second nature to everyone.

So I’ll see you soon sweet Salone. Bring it on.