Tuesday 15 July 2014

Exits & Ebola


At the end of the week in which we heard the news that the community health officer and three nurses from a health centre in a village just a few miles away from Segbwema had died from contracting the Ebola virus, we decided to give up our game of chicken against the onward progression of the epidemic of the dangerous virus that has now killed over 500 people in West Africa and return to the UK slightly earlier than planned. 
           Although, in part due to the continued expansion of the outbreak, more expertise and support now appears to be getting to where it needs to, in those first few weeks when cases were rapidly appearing in our district of Sierra Leone, the atmosphere felt very unsettled. In the days before we departed I had been alone at the hospital, with limited personal protective equipment (gloves and aprons) and my main source of information on new cases and deaths was through my friend Victor who owns a small bar in the village. 

While news of the outbreak quite quickly made it onto the headlines of the BBC world service with comments from the World Health Organization and Medicine Sans Frontiers, the reality on the ground felt very remote from a radio studio. At the time I had a patient (herself a healthcare worker) who worryingly had a fever that wasn’t resolving despite treatment for malaria and bacterial infections. However despite the increased media coverage, trying to get advice on how to ensure she was tested for haemorrhagic fevers including the Ebola virus was no simple task. After several unsuccessful attempts at contacting a surveillance officer I then had to personally find a motorcycle rider and pay them to take a blood sample to the laboratory in Kenema. The next day when I phoned the surveillance officer to chase up the result, I was a little concerned to say the least at his initial response of ‘what sample? I didn’t receive any sample...’ Thankfully several phone calls later I was able to establish the sample had been tested and was negative. Although undeniably our decision to leave was one based on self-preservation, and there is naturally a feeling of guilt about our friends and colleagues we left behind, at the time, flying blind against a virus with a mortality rate of up to 90%, with just a box of out of date latex gloves for protection, is something that instinctively felt like a bad idea.  

 Since being back in the UK although there have been on-going difficulties with communities not wishing to engage with the health services to prevent further spread of the disease (perhaps not unsurprising given that significant number of people in rural areas do not trust western medicines but rely on traditional healers), when I spoke to staff at the hospital a few days ago, I was relieved to hear that they had now received appropriate quantities of personal protective equipment and training and that all the staff members remained safe.

In the midst of a difficult few weeks at the hospital (both related to the outbreak and not) one joyful moment came when one of the hospital’s long serving nurses gave birth to a healthy baby boy. Despite looking ready to burst for some weeks she had continued working devoutly. On this particular Tuesday morning she was looking even more exhausted than usual. When she came to see me on the maternity ward after her shift had finished she confessed to me that her waters had broken the previous night but she thought she should come to work to do her morning shift first before seeing the midwife. After assessing her with the midwife, she finally succumbed to the fact that the time really had come when she needed to stop working. Thankfully she delivered a healthy baby boy later that night. The next morning I could see a moment of panic on her face before she realised I was joking when, after congratulating her, I said that we could give her the afternoon off to recover but could she work the night shift instead? It is a testament to her commitment as a nurse that she continued to care for her patients up to just hours before she needed a hospital bed herself.

Goodbyes were naturally difficult; perhaps most to my friend and colleague Tamba Missa, the medical superintendent who has run the hospital with or without support from the end of the civil war when he slept on the clinic floor for several months. As in all professional and personal relationships we have had our turbulent moments resulting from the frustrations or failure of a given situation but our connection both as doctors and friends has grown stronger over the months we worked and lived together.  The physical cooperation in surgery naturally lends itself to a sense of camaraderie and I will sorely miss those moments when we were jointly delivering a baby during a caesarean at midnight, but I will also greatly value the shared pleasure of seeing a complex unwell patient on the medical ward pull through as a result of pooled knowledge and experience. For me perhaps the defining moment when we became friends as well as colleagues was when he came running into my house saying he needed to hide from repeated groups of school children collecting funds for various projects who kept knocking on his door! Or perhaps when he confessed to me that his technique for avoiding shaking hands with some whose hygiene he wasn’t convinced by was to suddenly start pretending to search for his phone in his pocket; something that I had seen him do repeatedly and was always confused by!


I know that during our time at the hospital we have barely scratched the surface in beginning to deal with some of the difficulties the hospital and community faces in ensuring access to medical care; such problems and inequalities will take decades, if not generations to solve. However, I hope we have been able to leave some imprint with a few of the people we have had the opportunity to live and work alongside, as they have left their impression with us; the student inspired to pick up a book from the library shelf and then beaming with their certificate as they win an essay competition, the mother of a premature baby who brought her once tiny infant back to me in clinic healthy and smiling after months of kangaroo care (where the baby is held skin-to-skin almost continually), the community on the TB ward whose faces lit up when we brought a food package, the staff member who now knows how to deal with a woman who bleeds during her delivery, the small boy who turned up at the door every day from 7 ‘o’clock onwards to ask repeatedly if he could borrow one of the toy cars with his gentle persistence of the phrase ‘I play with car?’,  the simple pleasure of a shared Friday beer with my friend Victor or the mutual celebration after hours of sitting next to this laptop with the medical superintendent of him being able to send an email independently.  


Although the last year has brought with it many extraordinary experiences it is not something that can or should be packaged up as an entity to be left in a box as something to reflect on; there should be no convenient distinction between here and there, this year and the next, the privileged and the needy. Whilst pragmatic issues of careers, money and families lead us to re-integrate back to our lives in the UK our relationship with the hospital and with our friends will continue, all be it initially from a distance.


Thank you for reading and excusing (or highlighting) my mistakes over the last year.

Update 20th August 2014: Very sadly over the last month 5 members of hospital staff  including 4 nurses have lost their lives as result of the Ebola outbreak.