By Dr Oliver Johnson
Programme Director
King's Sierra Leone Partnership
Last year I had the opportunity to spend time in Boston with Dr Paul Farmer, founder of Partners in Health, who generously gave me a copy of his recent book Haiti After the Earthquake, an account of the response to the devastating earthquake in Haiti in 2010.
Programme Director
King's Sierra Leone Partnership
Last year I had the opportunity to spend time in Boston with Dr Paul Farmer, founder of Partners in Health, who generously gave me a copy of his recent book Haiti After the Earthquake, an account of the response to the devastating earthquake in Haiti in 2010.
Reading his
description of their early work in the main hospital in Port-au-Prince, a
sprawling colonial compound in need of a major revival, surrounded by urban
slums, I was struck by the parallels with our own partnership with Connaught
Hospital in Freetown – and have been kept awake at night since by an unresolved
question: what would we do in similar circumstances, if disaster hit Sierra
Leone?
On 25th May 2014 disaster did arrive, not in the form of an earthquake, but with the confirmation of the first ever cases of Ebola in Sierra Leone.
The news was not
a complete surprise – since the outbreak started in Guinea in March, the Ministry
of Health & Sanitation had been on high alert, organising regular National
Emergency Ebola Taskforce meetings to coordinate preparedness and contingency
planning.
On 25th May 2014 disaster did arrive, not in the form of an earthquake, but with the confirmation of the first ever cases of Ebola in Sierra Leone.
Myself with Connaught staff Dr Martin Salia and Sister Cecilia (Sister-in-charge of A & E) preparing the isolation ward.
The King’s team were invited into this process within hours of the first Taskforce meeting, advising Connaught on how to adapt international guidelines to develop a Hospital Preparedness Plan that detailed how to identify cases, set up isolation facilities and safely protect staff and dispose of medical waste.
We then had two months of relative calm and many began to believe that, even as Ebola had spread like wildfire across Guinea and into neighbouring Liberia, Sierra Leone might have dodged a bullet and avoided the outbreak entirely. The confirmation of cases within Sierra Leone quickly dispelled that hope, pushing us all to lift our game.
As the King’s
team worked to urgently provide refresher training to nursing and medical
staff, suspected cases began to emerge. Sierra Leone has been awash with
rumours and misinformation for weeks about Ebola and, with a nurse having been
one of the first Sierra Leonean victims, the sense of fear amongst hospital
staff was palpable. We therefore found ourselves amongst the first responders
to these suspected cases, alongside heroic Connaught colleagues such as Sister
Cecilia (Sister-in-Charge of the Accident & Emergency Department) and Dr
Eva Hanciles (Head of the Intensive Care Unit) who did not hesitate to step
forward and manage the response.
Our volunteer clinical
team were all re-tasked to provide support including consultant physician Dr
Terry Gibson, junior doctors Dr Paul Arkell and Dr Sakib Rokadiya and nurse
Karlin Bacher. They have been working late into the night to set up an expanded
Isolation Unit and to provide treatment and take blood specimens from
suspected patients. It has been sweaty and exhausting work, scrubbing floors
with bleach whilst wearing gowns, masks and other personal protective equipment
in the intense heat of Sierra Leone’s humid rainy season.
As we approach
the end of the frenetic first week of the response, we are finally getting a
chance to reflect on our response and the whole team has engaged in deep debate
about a number of ethical challenges we have been confronted with.
The most
fundamental question is whether we as an organisation should be involved in the
response at all. Just like our Boston colleagues in Haiti, our work at
Connaught Hospital is not aimed at providing hands-on clinical care to patients
or at directly managing clinical services. Instead our focus is to support the
long-term strengthening of the health system by providing training and
technical advice. This represents a fundamental distinction between
humanitarian and development work.
We’re therefore really
not set up to provide a humanitarian response, it’s not what our team
specialises in and we don’t have access to the sorts of funding or medical
equipment that are needed for this. On the flip side however, we have a highly
professional team of experienced clinicians, with two
consultant-level physicians, two junior doctors trained in tropical medicine,
two nurses, a pharmacist and a hospital manager, we have one of the largest and
most senior international medical teams of any organisation in Sierra Leone.
With that comes our close working relationships with local counterparts and our
relative familiarity with the hospital facilities, culture and the Krio
language. And we are on the ground already – whilst other international organisations
take weeks to recruit a team and prepare for deployment, we are able to respond
within minutes to a request for support.
Helping to
respond to an outbreak of a viral haemorrhagic fever (VHF) is not a standard
request for support however - it requires specialist expertise. We were lucky
to have Dr Colin Brown on hand, our Infectious Diseases Advisor in the UK, who
is well trained in VHF response and can draw on technical support from Public
Health England and beyond. Even so, are we acting beyond our competency and
putting ourselves and others at risk by taking on roles that we’re not set up
to handle?
After discussing
this as a team, with our local partners and with our senior colleagues back at
King’s we decided, on balance, that we had a duty to respond and that we did
have the capacity to do so safely and effectively – provided we coordinated
closely with other specialist partners (such as the Lassa Fever Centre in
Kenema and the World Health Organization).
Setting up the isolation ward at Connaught Hospital
Setting up the isolation ward at Connaught Hospital
The decision to
respond opened up a question about whether or not to put our staff on the front
line. Ebola is highly contagious, particularly through exposure to body fluids
such as blood, saliva or urine – this means that health workers are
particularly at risk. Effective use of personal protective equipment (such as
gowns, masks, goggles and gloves) and effective cleaning and waste disposal can
significantly reduce this risk but at the start we didn’t have all the
materials we needed available and you can never eliminate the risk entirely.
Different
organisations in Sierra Leone have responded to the outbreak in different ways.
Some immediately evacuated international staff when cases in Guinea emerged.
Others said they would do so if there were confirmed cases locally. Some put
restrictions on their staff, banning them from undertaking clinical work or
going into clinical areas. One organisation actually closed their entire
hospital to all patients.
This is a moral
dilemma in the truest sense, every option available involves moral wrong and
ethical compromise making it a matter of judgement about how to weigh up
competing responsibilities.
As organisations
we have a duty of care to our staff, not to put them at unnecessary risk. We
also have to be mindful of reputational damage; many NGOs worried that if one
of their staff members died of Ebola they would open themselves up to being
prosecuted or to funding being withdrawn, damaging their wider efforts to help
patients.
As health
professionals however, we have a duty to our patients. Withdrawing from
clinical activities would not only harm patients who are suspected of Ebola,
but (particularly in the case of the hospital which closed) would have
enormously detrimental impacts on the care of other patients. One NGO stopped
doing outreach clinics in a local urban slum – a clinic which was the only
health service available to many vulnerable patients, some of whom will
certainly have died as a result. And having made this decision, at what point
do you decide it is safe enough to return – for how many weeks, months or years
do you stay away?
Most of the
decisions made by international NGOs hinged around their international staff –
but what of Sierra Leonean health workers? Is it not discriminatory to withdraw
internationals whilst expecting local staff to stay at their posts and face the
challenge alone – especially when international staff are often better trained
in how to wear protective equipment and are at a lower risk as a result.
One senior
colleague at the Ministry of Health articulated this clearly – to him and his
staff on the ground, it felt like the civil war all over again, as NGOs packed
their white SUVs and abandoned their local colleagues at the first sign of
danger, often without even telling them of their plans. In this context, was
closing the entire hospital, and providing the same protection for all staff, a
more ethical decision – even if a greater number of patients ultimately died as
a result?
At King’s,
following extensive discussions with senior colleagues in London and Freetown,
we took the decision not to restrict the clinical activities of our team. We
were aware however that all our staff are volunteers and that this isn’t what
they originally signed up for – so we gave them the option to withdraw from
clinical activities if they wanted to, asking only that they make this decision
in advance so that we could communicate it to partners and put contingencies in
place. All of our team have decided to continue clinical work for the moment –
but has this put unfair peer pressure on individuals to agree to remain, since
everyone else in the group has decided to do so?
King's volunteer Dr Sakib Rokadiya dressed in protective clothing before assessing a suspected Ebola patient
(who later tested negative to Ebola).
The moral maze does not stop here though. The only way we can test for Ebola is to send a blood sample to Kenema and results can take anything from six hours to days. When a patient comes to the hospital who fits the agreed case definition we have to isolate them immediately. The case definition is broad, so most suspected cases turn out to be negative, in which case the patient is likely to have another critical illness such as malaria. But those patients cannot have any other diagnostic tests until their Ebola result comes back negative, because it’s too dangerous to expose lab staff to potentially hazardous samples.
The range of
treatments we can offer them is also severely limited – in particular, the
National Case Management Committee agreed that it was usually too dangerous to
perform surgery on a suspected case. For example a woman in obstructed labour or a patient with a surgical emergency like appendicitis might well have symptoms that match the Ebola case definition.
Patients and
their relatives are, understandably, deeply unhappy about being placed in isolation
and are often terrified by being kept in an Isolation Room and treated by staff
in masks. They are angry about not receiving better care and therefore often try to escape with the assistance of relatives.
Seven suspected patients escaped from Kailahun hospital last Saturday, with lab
results later showing that some of those were confirmed cases. This creates a
massive risk of spreading the disease.
At Connaught our hope
was that by providing better conditions and clinical care in the isolation room
and communicating effectively, patients would not attempt to escape. But so far
this hasn’t proved enough and the police have been called in for support. Do we
now lock suspected patients in the isolation room or call in the army to
contain them at gunpoint? Or do we respect their right to leave and risk letting
the outbreak spread out of control?
Managing this
outbreak has been an enormous undertaking for all involved – from senior ministry
staff holding daily meetings, to health workers leaving the wards to attend
training and money has been reallocated from other programmes. But is this disproportionate?
People die from malaria every day in Sierra Leone – but there have only been a
total of three confirmed deaths from Ebola so far. We know that Ebola is killing
people, but is the Ebola response killing people too? Should we instead be
putting our efforts into preventing other bigger causes of death?
None of these
questions have easy answers. We at King’s have done our best to identify the
ethical dilemmas we face and to respond to them with integrity, in consultation
with our own team and our local partners. I don’t doubt that we’ve got some of
our decisions wrong. Part of a rigorous approach though has to include opening
them up for debate, so we welcome your feedback and suggestions and hope to
initiate a broader discussion on how we can provide organisations and
individuals with better guidance and advice for future scenarios. As the rainy
season starts, concerns about a repeat of the 2011 cholera outbreak in Sierra
Leone are emerging and Connaught Hospital has been asked to start contingency
planning. Should we be repeating the same role for cholera, or position
ourselves differently?
In the mean time,
we’ll be back on the frontline in Connaught Hospital doing what we can to
support our Sierra Leonean colleagues to control this deadly outbreak.