Wednesday, 25 November 2015

Its all about the money

Ebola is evil and of course money is the root of it, and its enduring impact. The lack of investment in the public health infrastructure following its decimation during the civil war, both in Sierra Leone and Liberia, undoubtedly contributed to the spread of the epidemic through poor urban communities with little access to clean water. The World Bank estimates the international community spent $1.6 billion on the emergency Ebola response. A fraction of this invested after the civil war would have gone a long way to preventing the outbreak and saving a huge amount of money. Prevention is better, and cheaper than the cure, but its the headline-grabbing treatment that tends to persuade the public and politicians.

Sierra Leone is 183rd in the UN Development Index, and Liberia a lofty 175th, out of 187 countries. The main industries of tourism and mining scarpered at the first sign of Ebola. The tourists are reportedly starting to trickle back, but I didn't see many sombreros and Hawaiian shirts at the airport - all the white people had aid worker written (often literally) all over them. The mines are also starting to open, but the price of iron has plummeted apparently and many remain closed.

It is a fertile country with great mineral wealth and Bounty-advert beaches, so the potential is there, and if there was a hedge fund trade on the UN Development Index it would be good bet to place money on economic improvement.

Moyamba itself looks as though little has changed since the Victorians were here. Outside of the town it looks as though little has changed since biblical times. There are few jobs and subsistence farming is the mainstay of survival. The daily chores of carrying water from the well, washing and fetching firewood are done with sense of community and bonding.

On the plus side levels of inequality are low - everyone is poor. And no one around here is overweight - a simple diet and the physical activity of daily routines keeps everyone fit. And people seem pretty happy. I am struck by the contrast most when I travel back from a rural African town to the UK. One day I can be at the centre of TB/HIV/Ebola epidemics, but I will stand in the main street and marvel at the laughter and love that fills the dusty air. A few hours later I will be travelling through London with the grim-faced commuters. Actually, its not all about the money.

There has been an Ebola dividend in Moyamba. Large amounts of money have flowed into the town to build the ETC and then create precious jobs - hundreds of them. People have been happy to take on high risk jobs that come with a danger supplement. But now they are all being made redundant and the future is dim. Perversely most of the ETC would rather the epidemic continues so that they are able to maintain an income.

I am back in Freetown, luxuriating in a room at the Seaside View - my own room, running water and electricity. Food that is not peanut-chicken-rice. I sleep more hours in my first night than the entire previous week.

The hotel lives up to its name by providing a view of the sea. It is one of a row of similar tours hotels lining the rocky Atlantic shore. All of them completely deserted. I look out over an abandoned hotel extension: a throw-back to more optimistic times. Chinese factory ships trawl up and down the sea lanes offshore - making fish while the sun shines. Making a lot of fish while the sun shines, and with no local coast guard to enforce territorial waters.

I join the mad dogs in the heat and explore my neighbours. A giant international conference centre stands forlorn and empty. Idris the security guard of a nearby hotel invites me in to admire the marble and mezzanine. I feel I am a sole survivor in a post-apocalyptic world.

On the plus side, schools have opened after a year of closure. Every school has its own isolation unit in the playground - built with simple traditional materials. I am mobbed by children when I inspect its water and sanitation facilities. 




Monday, 23 November 2015

Something for the weekend

The weekend has been reclaimed from Ebola-work with a rest day on Sunday. However three new cases in Liberia after nearly two months of Ebola-freedom jolts us from the celebratory complacency. Like the fight against IS, the fight with Ebola is asymmetric warfare, striking when we least expect it.

There is a national Thanksgiving Day for the end of Ebola and Moyamba does its bit by holding a multi faith celebration. Around half the population is Muslim and half Christian - living together in a model of peace and mutual respect. Community leaders gather at the Ebola Response Centre to give thanks. The 9am start stretches and yawns to mid-morning when proceedings finally kick off.

Europeans have lost the art of public speaking. We are too self-conscious in our aim to get across the key messages. Too nervous to do without powerpoint or autocue. Africans in contrast can hold an audience for hours with their narrative skills, and we sit in awe of the Moyamban loquaciousness but also vain hope that they might revert to bullet points.

The Christian community leader starts off with a praise-the-lord thanks for the end of Ebola, but his oratory soon deteriorates into comparisons with Sodom and Gomorrah and Gods punishment for homosexuality. Ebola has been the Lords punishment for all our terrible, debauched sinning he cries out, scanning the room until his gaze finally settles firmly on me. I freeze. How the feck does he know?

The weekend is also the time for the Premier league and a chance to live show off local passion for English football. Man United is the most popular team, followed by Arsenal, Liverpool and Chelsea. Saturday afternoon find everyone sitting around TV screens watching all the live matches. No Sky subscriptions needed in Moyamba. Every time a goal is scored, wild celebrations break out with shouting and laps of honour round the room - more exuberant celebrations than the on-screen goal-scorers.


The base camp has been finally abandoned. We have all been moved to a guest house in town, exchanging our shared air-conditioned tents with cramped, shared, non-air-conditioned rooms that become sweltering saunas in the night. The lack of sleep sparks an atmosphere of irritability made worse by the disruption to our twice daily addiction to the peanut-chicken-rice staple diet.

The ETC is also coming down around us. There are also an increasing number of thefts going on despite the G4S security guards (or perhaps because of). Yesterday it was 14 mattresses. Mattresses? Not the sort of thing that you stick down your trousers as you walk past the guards. Let them have it all is my view - better to leave all this Ebola bounty to local people than whisk it back to the UK where second-hand Ebola mattresses are unlikely to meet their asking price on Ebola Ebay.

The district health team want to take over the solid buildings at the Centre, but I am not convinced this is such a great move. Despite the skill of the Royal Engineers, this is not a place that will survive the ages, even months. Next to the Chinese factory making iPads for demanding Californians, is a factory making stuff for Africa, and it is crap. Yesterday one of the French aid workers flushed the toilet and the whole cistern, bowel and pipes shattered and collapsed, leaving her left holding just the metal handle with nothing attached to it.

It is a message from God. The one that the Christian community leader follows. I pack my bags and head to Freetown. My work here is done.

I will miss Moyamba. Everywhere I go people shout Doctor John in a sing-song greeting, laughing and waving. They may be laughing at me, but I dont care. I love the joy of it, and might introduce it as a compulsory greeting for my team in Bradford. As I leave the ETC for the final time the guard at the entrance hugs me and points out that I was the first doctor in and the last doctor out. Like a party guest that you just cant get rid of. 


Saturday, 21 November 2015

They will survive

Following the strange case of Pauline Cafferky I am keen to find out what is happening with the ETCs Ebola survivors. Ebola appears to linger in our bodies after infection. Just as herpes virus lies dormant in our spinal cord after childhood chickenpox, and returns years later as a cold sore. There are immune privileged sites in our body such as our eyes, spinal cord and in males, testes, that remain remote from our immune system.

The American doctor Ian Crozier recovered from Ebola to find one of his eyes changing colour from blue to green - active Ebola virus replicating in the aqueous humour of this eyeball. What a scary thought when he looked in the mirror - something out of a horror film. Pauline Cafferkey had a post-Ebola meningitis and fortunately has recovered. A paper in the New England Medical Journal found that Ebola could remain in semen for up to 9 months following infection and there has been one case at least of Ebola being sexually transmitted.

So what about our Ebola survivors? I met up with two of them. Philip (photo) and his family had all been infected with the virus. His father and two brothers had died, he and his two sisters had survived after successful care in the ETC. He had recovered fully and was now training as a community health worker so he can care for future patients, which was a wonderful completion of the circle. Mohammed had also lost members of his family and was suffering from on-going health problems and struggling to find work.

Clara is a psychologist from Madrid and runs the psychosocial team looking after around 100 local survivors. She tells me that they face two hurdles after they walk out of the happy shower at the ETC. First is the fear that they still have the virus. Some of the wives of the men have refused to have sex with them for fear of contagion of Ebola STD.

The other hurdle is acceptance back into their communities. When I was here last year the survivors I spoke to faced real stigmatisation and rejection. Their friends and neighbours were scared of catching Ebola from them. This has changed dramatically over recent months. The end of Ebola has helped of course, but education and awareness and contact has overcome the prejudice. A powerful example of overcoming discrimination in society.

A weak link in the chain for many of them is the loss of other family members. The nature of Ebola meant that it tends to effect clusters in close contact. Many of the survivors were struggling with the loss of their family support network, and perhaps survivor guilt.


They are still collecting the data on sequelae, but the preliminary data suggests that about 50% of patients have on-going physical symptoms - uveitis is common, joint pains (bilateral, affecting upper and lower limbs) and headache. Some have experienced hair loss. There do not appear to have been any serious complications such as meningitis, but some of the patients do live in very remote areas, so keeping track of them can be a challenge.

Last month the team managed to get 90 of the survivors together for a celebration last month. It was a special occasion - much dancing and singing. All members of a very special club: they saw Ebola and lived.

I return to the Ebola cemetery on the outskirts of town. The last time I was here was to arrange a burial for one of our first patients. There were a dozen grave diggers in full PPE sweating away in the heat to dig the deep Ebola graves. This time the place is deserted, but the number of grave markers has grown to hundreds. It is a beautiful and tranquil resting place and I suspect within a year will be overtaken by the jungle and return completely to nature. However it will always be a memorial to those who were not lucky enough to survive.




Friday, 20 November 2015

While you were gone….

Ebola has inevitably been the focus of everyone’s attention in the year since I was here. But while the national and international community were away fighting the epidemic, the humdrum diseases of everyday Africa have been chomping away on their human hosts.

My colleague James Elston had undertaken a wonderful health needs assessment in Moyamba in February and I was keen to see how this had changed with the end of the epidemic. I set off on my Grand Tour of Moyamba district - like the Grand Tour of Europe, but hotter, dustier, bumpier and with fewer classical antiquities.

First stop was Moyamba Hospital where I was reunited with the impressive Dr Jonjopi who is almost single-handedly trying to keep the hospital running in the face of government apathy. They are running out of so much basic supplies (needles, gloves, scalpels, oxygen, drugs, lab kits) that I fear they may soon have to become the country’s first homeopathic hospital.

The gulf in resources between our ETC and the hospital is disturbing. At the ETC we sit at our laptops in well-stocked, air-conditioned offices. Our pharmacy bulges with the latest drugs and equipment. Our supply tents are veritable Aladdins caves and outside a fleet of shiny 4x4s sit waiting to whisk us to our next destination. Yet we have no patients. Meanwhile at the hospital a battered ambulance lies rusting in the humid heat. The pharmacy cupboards are bare. The laboratory has run out of basic equipment, even needles to take blood. The ETC is the Harrods to the government hospital’s car boot, and it must be galling to watch us pack up all our riches and fly it thousands of miles back to the UK when it could save many lives just down the road.

The one thing that Dr Jonjopi wants most is power. Not in an evil villain way - just electrical power. The circa 1960’s generator had given up the ghost earlier in the year and now the hospital had no electricity. Meanwhile down the road at the ETC we have enough spanking new generators to light up a small European city. Even our base camp (population: 13) had two large generators.

Moyamba hospital                                                Base camp 
When I was here last year I was able to requisition some of our vast mountain of DFID supplies and surreptitiously sneak them down the road to the hospital. Technically this might constitute theft from the UK tax payer, so I better keep it quiet from the GMC. However this time I am a spectator and layers of bureaucracy have grown up at the ETC like the Moyamban jungle around us, so I cannot redistribute from the rich ETC to the poor government hospital. However I promise to lobby DFID to leave one (just one itsy, bitsy generator) behind. No one will notice back home.

Dr Jonjopi has undue confidence in my ability to pull this off based on previous experience and the folklore legend that I have become in these parts, with my own nickname in the local language (Thieving Bastard Wright - it sounds much better in Mende).

Next, to a Maternal and Child Health Post - one of the basic units of the district health system, serving about 4000 people. The nurse running it was alas away on a training course (infection control!) but there were a team of three ‘Ebola screeners’ on guard duty to check temperatures, oversee hand washing and permit onward travel into the clinic. They wear goggles when taking my temperature which seemed a bit OTT, but assured me this is government protocol. Not quite the ‘have a nice day y’all’ front of house welcome I was expecting.

Then a long bumpy journey later, onto a Community Health Post, the next step up in size. It was closed. More training we were told. Note to self: do not fall acutely unwell on a training day. Onwards through the day to a Community Health Centre (the big mummy of health clinics covering 15,000 people) where we found nurses and health officers trying to hold back the tide of ill-health.


My tour continues, bagging a few more MCHPs and CHPs before my shock-absorbing back capitulates under the attack from the unmade roads and I return to the basecamp with the following conclusions:

1)    People are returning to the clinics. Any fear of that these are plague centres has lifted with the end of the epidemic. However the traditional healers remain an important first point of contact.
2)    The physical capital of the clinics is not bad. A bit shabby and could do with a big, slobbering lick of paint.
3)    They all lack running water. Some of them have sinks and water tanks, but none of them function. This is pretty fundamental when trying to implement a ‘now wash your hands’ campaign and there is nowhere to wash them.
4)    The larger clinics have a solar panel to run the single fridge that maintains the cold chain, for vaccines but like the hospital they tend to lack power.
5)    Essential drugs are better stocked than I anticipated, but some basic gaps, particularly paediatric medicines, from delayed supply.
6)    Rapid testing malaria, TB and HIV kits are all available. There is a shedload of malaria positive results (that’s a technical epidemiological term), but few HIV positive cases or TB positive AAFB smears. Given the level of HIV/TB in many African countries this is an encouraging sign.
7)    The health workers are impressive, but a bit demotivated. Too much top down management and not enough bottom up improvement.
  
I suspect that the historical routine public health data that we have been using to evaluate trends in diseases is not reliable and resolve to spend tomorrow with the district surveillance team.




Thursday, 19 November 2015

Camp life

The Norwegian base camp is oddly comforting - I think I may have become institutionalised to communal tent-living with its nocturnal chorus of sighs and snores. However it is rapidly coming down around me and I fear I will be soon homeless. Please don't send me back to the abandoned stadium.

The atmosphere has changed completely since last year. The Norwegian military team did a great job in setting it all up in adverse conditions and looking after us with warm Nordic hospitality, but it was a bit rule-bound and Ebola-paranoid. Now the camp is run by an old Africa-hand Italian who is much more laid back. The atmosphere is more mooching than military, and beer is back on the menu.

The camp apartheid has gone with the lifting of bans on nationals in the camp and it feels much more integrated. Local people have replaced the Norwegians working in the camp and are providing the catering - local flavours and foods (well, fried chicken and rice every night) rather than fish flown in from Oslo.

The Wi-Fi has improved dramatically and there are fewer people to drain it with their devices so I don't have to go begging for internet. Last night the generator failed so we have no power or water and we are all a bit smelly, hungry and Wi-Fi-deprived today. There is the option of the happy shower at the ETC, the one survivors took before they left the red zone, but its heavily chlorinated so there are few takers.

Our polyglot, Babelian community is small and strangely disconnected, thrown together from different countries and different teams - tribal by permutation. The newbies sporting branded NGO T-shirts while the old pros lounge around in faded designer fashion. There is a preponderance of young Mediterranean men with beards who look unnervingly similar and disconcertingly handsome (all you single ladies - think about Moyamba rather than match.com; all you hen parties - give York a break!).

They fill the nocturnal gatherings exchanging stories of near-death experiences from tours in Afghanistan, Somalia, Sudan, CAR. It is an ephemeral life that they live - going from one mission to the next. The balance between their passion to make a difference to the world and keeping down a normal life (boyfriends/girlfriends/children) is a high-wire act. And they all smoke of course; water engineers who spend their lives making clean water and dirty lungs.

There is a new plague to replace Ebola in the camp, this time from Nairobi flies. When you slap them as they bite, they release a chemical that causes a paederus dermatitis with nasty inflammation and blistering. Sierra Leonian versions are particularly severe I find from Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/17459295). The key is to flick rather than slap when bitten, and we spend our time at the camp performing a strange chorea-form dance to each other.



Wednesday, 18 November 2015

'Bradford's latest weekly notification report....'

There is a calm efficiency to the decline and fall of the Ebola Treatment Centre. The opening was a madness of urgency and rush. Today the international staff sit relaxed in front of laptops showing spreadsheets of logistics and the watsans continue their slow but methodical dismantling.

Was it all worth it? The final score for Ebola in Sierra Leone was 14,089 cases, 10,134 survivors and 3,955 deaths. A survival rate which looks a healthy 72% is flattered by a reporting bias. All the survivors will have been identified, but many of the deaths will have been missed in the community. A good illustration of this can be found in the health workers. These are much more likely to have been picked up and reported, and out of the 307 cases only 86 survived - an identical rate of 72%, but this time flipped from a survival rate to a mortality rate.


My arrival in the country last November coincided with the peak in reporting in the country, and my departure with a reassuring trough. While it is tempting to claim causal attribution, this may be pushing the interpretation of the evidence (though I will include this on my CV).


A recent paper in the Proceedings of the National Academy of Sciences attempted to model what the impact was. The authors estimated that the opening of the 12 Ebola Treatment Centres saved 57,000 lives - an impressive result in todays underwhelming medical world. I felt at the time that we could have arrived on the scene earlier. The authors look at this too and estimate that an extra 12,000 lives would have been saved if the ETCs had opened a month earlier. Not as many as I expected.


There has been an opportunity cost to all this frenzied activity. Immunisation rates have fallen as families stay away from health centres. Family planning services have been shunned and other infectious diseases neglected. The longer term consequences of this remain uncertain, but the urgency to rebuilding the health service is clear.

Decline in Moyamba immunisation rates before and during Ebola

Fall in Moyamba clinic attendance comparing before and during Ebola

The first step for this rebuilding is to re-establish the trust of the community in their health services - a tricky thing to engineer and something that will come naturally with time as the epidemic recedes. The MDM/DOTW team in Moyamba are working with partners to strengthen clean water supplies and hand washing - starting with all the schools in the district. Training of the community health workers comes next - better identification, reporting and referral of all infectious diseases. I attend one of the local workshops where the district health team go through the list of 47 tropical diseases that pose an everyday threat to the community. While some are exotic (Monkey Pox)? Chiunkunya? Dracunculiasis?) others are routine (measles, cholera) and as always malaria remains the top assassin. 

I sit down with the local surveillance team reviewing their reports and systems. One of the key achievements since I was last here is setting up a closed user group mobile phone system which enables the surveillance officers to communicate effectively with the 100 district health units. I check out Bradfords late report which highlights the ongoing threat from malaria.

One of my goals is to explore how we can strengthen the local health system. It feels a bit too centralised and top down - national guidelines via WHO and the ministry pouring out from Freetown onto a demotivated and demoralised workforce. It is a similar problem in the UK but at least we have the insight to recognise that implementation and improvement need a more grass roots approach: understanding the local context, good leadership, ownership, understanding the facilitators and barriers to change, behavioural change approaches and effective implementation strategies. The ETC remains the focus for everyones attention in Moyamba, but it is irrelevant now, and our attention should be on the wider health system. Tomorrow I will head out to some of the rural clinics to find out what is happening in the field.

Tuesday, 17 November 2015

How to dismantle an Ebola bomb

I am strangely nervous about returning to the ETC on my pilgrimage to Moyamba, coming back to the battlefield one year on, after the war has been won.

The last patient was discharged a couple of months ago, and I half expect a deserted facility so am surprised by the level of activity I find. Groups of staff in surgical scrubs are busy at work decontaminating and dismantling the Centre. They greet me with a touching joy and warmth.

I move from group to group exchanging greetings and news. The site is still a high risk centre for Ebola contamination, but after a year of avoiding body contact everyone is demob happy and we shake hands and hug each other for the first time ever, savouring this forbidden fruit of touch. We exchange stories about the early days of the ETC - from recruitment and training to our first nervous shifts in the red zone.  Old soldiers recounting stories from the war.

There is great happiness about the end of Ebola, but a scratch beneath the surface and I find sadness and worry about the impending loss of their jobs. They were ready to take their chance with the acute threat of Ebola, but unemployment is the long term condition that they fear the most. There are no jobs in Moyamba and they face a bleak future.

There are only two nurses left working at the ETC. Janet and Rose welcome me with screams. Happy screams I am relieved to find. Janet was working with me when we admitted our first ever Ebola patients and tells me about two of our early survivors - Isatu and Safi. Both are back to good health. Isatu is pregnant now - new life from near death.

But it is their last day and tomorrow they too are out of work and demoralised. The health service has too little money to recruit their precious talent. The contrast is unsettling. I go out for a few weeks and get feted with undeserved glory. They put their lives at risk for the entire epidemic and get made redundant. Taking the example from Sonny Bill Williams I promise to send Janet my Ebola medal.

They are proud of their contribution to stopping the epidemic. Proud also that had no Ebola casualties in the workforce. A safe centre for its staff and its patients and one of the few ETCs to be able to make this claim. I take a final picture of them outside the nurses station, now covered with farewell graffiti like a school-leavers shirt.

How to dismantle a toxic Ebola hospital: a quick and easy recipe

Ingredients
1.    Tents. The tents have plastic walls and can be safely decontaminated with by spraying high strength chlorine solution. The roof is a challenge as its five metres high.
2.    Equipment. Mattresses, plastic buckets and metal trolleys are asked in soap and then sprayed in chlorine. These will be donated to the local community.
3.    Pipes and taps. The 0.5% chlorine has eroded all the metal pipes. No one is confident that rust and erosion can be properly cleaned from Ebola so, these will be destroyed.
4.    Wood. The wooden roofs and walkways, so beautifully constructed by the Royal Engineers from the finest African hardwood also have to be destroyed. WHO have decreed that as wood is porous and we know so little about how the virus can survive, no risk can be taken. Six tons of wooden craftsmanship have been dismantled and burnt in giant pits.


All the hard work of the Royal Engineers vanished in Ebola-consuming flames
Instructions
1.    Don full personal protective equipment (PPE) and enter the red zone.
2.    Soap down and spray with chlorine every surface making sure not to miss a single spot.
3.    Dismantle the wooden corridors bolt by bolt, nail by nail (dont get a nail-stick injury!), timber by timber.
4.    The temperature in your PPE will rise to over 50 degrees. The sweat will soak your mask and give the sensation of drowning while you are undertaking a heavy labouring job, so no more than 20 minutes attacks on the structure before you head for the doffing area.
5.    Repeat for two months

The chef for this main course is Xavier, a Spanish chemical and biological decontamination engineer who has had to organise a complex rotating system of dismantlers to manage the task.
Just sitting in the shade is exhausting in the heat and humidity and I thought that the clinical work in PPE was endurance-testing. Watching the watsans dressed in full PPE doing heavy construction work filled me with awe.