A second look

Bereh beach, beautiful but largely deserted

My first impression of Freetown was of life going on as normal but spend a few weeks here, talk to some locals and you realise life is anything but normal. To begin with the impact on the economy is huge. Some say the Sierra Leonian beaches are the best in the world, they are certainly spectacular but currently they are deserted as the tourist industry has collapsed. One of our drivers has seen his own taxi business implode and he now relies on working for the NGO to feed his children. Perhaps when this is all over a small silver lining will be that many new people have seen the country and would love to come back and visit.

Since May all schools, colleges and universities have been closed including the nursing college and medical school. Mass gatherings are outlawed so the football stadium lies empty although curiously church gatherings seem to be except. The bars along the beach are usually teeming with people and alive with loud music until the early hours but now they are almost silent. Just a few people prop up the bar with the quietest of sound systems playing, in truth they are supposed to be closed altogether. Even the public transport has changed; in Freetown cars are used as shared taxis to run along pre-determined routes. Normally there might be two in the front and another four in the back. To prevent too much body contact they are now restricted to one in the front and two in the back. Roadblocks are common and the rules strictly enforced.

At one point I wondered whether there might be perverse incentives for some people to keep the Ebola epidemic going, what with all the extra NGO’s floating around town hiring local staff. Nothing could be further from the truth. There are in fact far fewer NGO’s here than normal because all those not working on Ebola have understandably upped and left. It is true that some staff are being paid a ‘risk allowance’ but no-one I have spoken to values this above having their country back. You often hear people saying “after Ebola it will do this and that”, there seems to be an assumption that this will all be over sometimes early next year. Looking at the statistics I think we might still be running an isolation unit a year from now.

Risks and rewards

In the opening monologue of the film Trainspotting, Renton says “what people forget (about injecting heroin) is the pleasure of it, if it wasn’t pleasurable we wouldn’t do it after all we’re not stupid, at least we’re not that f***ing stupid”. On the face of it working with Ebola and injecting heroin don’t seem to have much in common but they do share the mixture of pleasure and danger which some people find addictive.

I’ve been highly introspective about my motivation for coming here and the reasons I enjoy it. One thing it definitely is not is altruism. That would mean incurring more risk than the rewards you get out at the end and I doubt many people are genuinely in that position.

The risks are hard to quantify but are real; while many local healthcare workers have died the mortality rate for foreigners who are evacuated to high resource settings is very low, in fact for those who recognise early signs of illness and are evacuated quickly the mortality rate is zero. That doesn’t take into account the terror of catching this illness and the concern it would cause to friends and family, not to say the cost, but it's some reassurance. I think that if the mortality rate for me was anything higher than about 30% I would be too scared to work here.

It has taken some deep introspection to work out the rewards that outweigh these risks. Firstly, there is definitely an adrenaline rush from being at the frontline of something really important. The outbreak has had devastating effects on west Africa and as a healthcare professional it feels like the most important place to be right now. There are always other places with competing needs and less media attention but right now this feels like the place to be. In short, if your normal life feels like the First division, this feels like a temporary shot at the Premiership. I can’t feel bad about that. It is true of many professions from the military to the media that you want to be ‘where the action is’ and I am no different.

There is more to it than that though. There is a side which feels like a guilty pleasure and that is the power and attention. I don’t like being the centre of attention at a social gathering, it makes me uneasy, but in a medical setting I think I enjoy it. My personality enjoys being the one out there in front of the hospital talking to the relatives in their time of need. I certainly don’t enjoy the power to decide who does or does not get admitted to the unit; that is something I could easily do without but being the one with the information and communicating with people at the gates is very rewarding and even intoxicating at times. That is difficult to share and doesn’t give me pride but I guess there are worse ways of satisfying a need for power and attention.

While my transition to the Premier league has felt pretty seamless I am not sure how easy it will to adapt to normal working conditions again. I common with many of my colleagues here I'm concerned that life back home might just feel too normal and bring on the depression that was expected after arriving here.

Heart-breaking

It might sound strange but so far I haven’t found the Ebola outbreak hugely stressful. It might be the constant work without time to reflect, it might be that it’s all building up inside, or perhaps my previous experiences of young people dying during the HIV/TB epidemic in South Africa have partly immunised me against the effects.

Despite this there are times when even the most hard hearted of people would be moved. I spend a lot of time outside the hospital gates talking to relatives who are often anxious, frustrated and desperate for news. I make an effort to give them as much feedback as possible and pass messages when I can. A pretty young woman  in a bright yellow patterned dress gave me a phone to pass on to her father inside, I knew his Ebola test had come back positive and he was preparing for transfer but I took the phone. As I stepped into the unit I heard that he had literally just died that minute. With a deep breath I went back out to the woman. She probably didn’t notice that the phone was still in my hand and came bounding up to me with a broad smile, I’m sure she was expecting some positive message back from her father. I didn’t smile back. Medical school training for breaking bad news is long an exhaustive but sometimes that just isn’t practical. Instead this poor woman had to hear the news on a crowded street outside a hospital gate. She collapsed in a display of grief that is typical in Africa and I left her with her family and drifted away into the crowd.

Later that day I was asked to see a 9 year old girl and a baby strapped to a woman’s back. A kindly local man in his 60’s with good English helped with translation; he said that as so often happens the children had been rejected by their compound after their parents had died of Ebola. Thankfully a young man had agreed to take them in but he was worried that they might be infected. Both were healthy but there was a suggestion that the girl had a fever. If truly a suspect this poor girl who had just lost her parents would have to spend at least 2 days in the isolation unit waiting for a blood result. The isolation unit must be a terrifying place for a child with faceless adults in big white suits walking around and adult patients dying in adjacent beds and this particular girl was even more vulnerable than most. She cried as we took her temperature, petrified that we might take her inside. Eventually we decided she was not a suspect and the man agreed to look after her and her baby bother. There must be hundreds if not thousands of stories like this in west Africa at the moment. This one at least had a reasonable outcome but many more surely do not.

Tough decisions

The holding tent outside the main hospital gates

 

 

Medecins Sans Frontiere are currently running a campaign called #toughdecisions. Initially I wasn’t sure what that meant but then it began to dawn on me. Working inside the isolation unit has its challenges but they can be trivial compared to those waiting just outside in the screening area. The first tough decision is which patients to choose to isolate.  It might sound like a cut and dried process but there are always grey areas. For example, a month of abdominal pain is very unlikely to be caused by Ebola as by then the patient would either have died or recovered. However, if the current symptoms are compatible with Ebola it is very hard to send them to the general hospital. You never know if you can fully rely on the history and even so it is possible to have Ebola as well as another longer lasting illness. Given the limitations of care in the isolation unit you really feel the patient would be better off in the hospital but on the other hand you are desperate to protect the staff from infection risk. While the bottom line must always be ‘if in doubt isolate’ you can’t help feeling for many on the borderline.

Tougher decisions still happen when there are more patients needing isolation than there are beds available and somehow we have to decide who is admitted.These patients wait in a temporary shelter just outside the hospital gates (see above). This is not a treatment area but a way of keeping track of patients and isolating them from passers by. Sometimes there might be 8 patients waiting, some are sitting up and talking, others are lying prostrate on the ground, in short it can look like a World War I medical area at times. Decideing who to admit may sound as simple as selecting the sickest patients; afterall they are the ones most likely to infect relatives if kept at home. However, some people have been sent by their families to get tested or have mild symptoms but be very anxious. Some might have sat outside the hospital all day or perhaps longer only to be told that a sicker patients has just arrived and will be given the bed. There are often patients in the holding area at the end of the day and they must either go home or wait until the morning (they are given a home kit with protective equipment and rehydration solution). Some may not have a home to go to as they have been rejected by their families after showing symptoms. Others may have family members with them pleading for you to take them in.

Choosing one patient over another under these circumstances has got to be the #toughestdecisions I’ve ever had to make as a doctor or a human being.



Protecting the hospital

                                                  Me in full PPE, it gets pretty steamy inside

Connaught is the largest hospital in Sierra Leone and houses a nursing college and the only medical school. Whilst Ebola might be the word on everyones’ lips it doesn’t mean that all the other illnesses have gone away, far from it. It’s not practical for everyone in the hosptial to wear full PPE the entire time so it's vital to screen and isolate any patient who might have Ebola before they get to the rest of the hospital. This is where the isolation unit comes in.

Every patient attending the hospital for any reason at all is now screened by dedicated team just outside the main gates. Screening is based on basic symtoms, measurement of fever and history of contact with known or suspected Ebola cases. To protect hospital staff screening must pick up 100% of Ebola cases but many other illnesses share symptoms so many non-Ebola patients also screen positive. Perhaps a third of patients admitted to the isolation ward test negative for Ebola.

The screening tent outside the hospital gates

 

This creates 2 problems, the obvious one is that negative and positive patients must share a ward. While great care is taken to prevent cross infection,  a small risk must still remain. The second is that negative patients might not get treatment for  their actual problem. It isn’t possible to do routine blood tests or X-rays because of exposure risks so we are often left in the dark. All patients are treated for malaria and common bacterial infections which hopefully covers some of the bases but clearly not all. The result is that a knock on effect of the Ebola epidemic is that peope with unrelated illnesses are also suffering, partly because the hospital is not running at full steam but also because of the need to protect the hospital staff by isolating them in a ward that cannot provide all the care they need.

This scenario makes the turn around time for Ebola tests absolutely critical. These issues would evapourate if there was a point of care test giving results in a few minutes or even hours. As it stands however, test results take between 1 and 7 days to come back and improving this is a high priority. If point of care testing became a reality there would be no need for an isolation ward at all as patients could immediately be directed to the hospital itself or a self contained Ebola treatment centre.

PPE

https://www.facebook.com/photo.php?fbid=10152431869881766&set=a.10151423403656766.1073741824.573386765&type=1&theater

Click above for photo

Most people could last about 90 minutes inside full PPE. You probably lose at least 1 litre of fluid an hour and there is no chance to take a drink as your mouth and eyes are the most vulnerable areas so you can’t remove your mask or put anything to your lips. It takes about 15 minutes to decontaminate so in total you can do this up to 3 times in a 6 hour shift. There are 2 of you plus a nurse or 2 and a cleaner for 18 patients.

Most of the work involves moving people either in or out of the unit. There can be anything up to 8 changes of patient per shift. When a bed becomes available we need to clean it and assemble a ‘welcome pack’ of rehydration fluids, a toothbrush and toothpaste.  Admissions are usually straightforward but all need medications. Dead bodies need to be cleaned and moved to secure body bags which can be hard physical labour inside a suit. Transfers need to be taken to ambulances and discharged Ebola negative patients might need admission to the rest of the hospital.

Often this doesn’t leave much time for actually caring for the patients although it is important to speak to each of them, offer encouragement to eat and drink and in some cases to site lines and give intravenous fluids. There are a range of medication available for pain, agitation, nausea as well as anti-malarials and antibiotics. Thankfully paperwork is kept to a mimimum but it is important to keep records of everything you do. When all this is done you find yourself sitting in the 'clean' office in a pair of surgical scubs that you could wring out sweat from and looking forward to something cold to rehydrate with.

How was your first day?

For once my preconceptions were actually pretty close to the mark. There was evidence in Freetown that Ebola is around, with symptom and temperature checks on arrival at the airport and public health billboards around the town, but overwhelmingly you get the impression of life going on as normal. It shares characteristics with other African cities I have visited in recent years such as Addis Ababa and Blantyre. There is hustle and bustle on the streets; women with strong arms carry their wares in big containers on their heads. Feral dogs duck for cover as cars weave around potholes and pigs feast in the litter strewn waterways. Big white 4X4’s with NGO logos jostle for space with local taxis as the odd blacked out Mercedes speeds by. Young men wear shirts from European football teams, usually with names like Ronaldo and Drogba across their shoulders. And boy is it hot! Something like 25C at 3:30am when I landed with high humidity and no respite.

I had seen pictures of the hospital so had some idea of what to expect. Contrary to my fears there is still a fair bit going on besides the Ebola work. Elective surgery is on hold and there never was a Maternity unit there but the standard medical wards are open for business. All patients are screened for Ebola symptoms at the gate and those deemed not to be suspects proceed to the Emergency Department and then if necessary to the wards. I’m told that the wards are quieter than normal but they certainly not as desolate as I had feared.

Those who fit the definition of suspected Ebola move to the isolation ward for testing and treatment, at least the lucky ones do. It is not safe admit more patients than there are beds so if the unit is full the patients have to wait. They may even have to go home if no alternative bed can be found. That's got to be heart-breaking news to deliver however hardened you becomes.

Its time to go...

Travel always challenges your expectations. I tend to have vivid ideas of what the new place will look and feel like and more often than not I'm way off the mark. So, what do I expect of Sierra Leone while sitting at Heathrow waiting for a flight?

In many ways I expect life to be going on as normal. I expect markets and traffic and noise and everything else that goes with a city in a poor African country. Will it be obvious to me from the window of a taxi that Ebola is lurking? Will people obviously be avoiding contact with each other and have fear etched on their faces? Somehow I doubt it.

What about the hospitals? Prior to the Ebola epidemic Sierra Leone had a broken healthcare system with one of the highest death rates from malaria and highest ratios of patients to doctors in the world. Clearly there is now an International effort to control Ebola so presumably there are far more healthcare workers in the country than ever before. My expectation is that outside of efforts to manage Ebola there will be very little healthcare activity. It can't be easy running any kind of primary healthcare under those conditions. How many children are being vaccinated? How many women are dying in childbirth and how many people with febrile illnesses unrelated to Ebola are staying at home for fear of being placed in an Ebola ward? Somehow I think a lot.

I'm sure people on the ground are well aware of this but a big fear I have is that the NGO sector will be so focussed on Ebola that everything else will be taking a back seat and a measles outbreak is on the horizon. I hope very much that this is another of my unfounded expectations.

Should we do Ebola trials using placebos?

I wrote this letter in response to an article in the medical journal the Lancet saying that it was unethical to use placebos in trials of treatments for Ebola. It wasn't accepted for publication (they published a similar but better written letter from someone else which you can read here-http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61735-9/fulltext) so i've decided to put it online.

Adebamowo et al write that randomised controlled trials (RCT) of treatments for ebola virus disease (EVD) are unethical1. I disagree. Their first objection is that randomisation is unethical based on a lack of equipoise. Equipoise exists when there is a lack of evidence of efficacy for an intervention and is disrupted only when data are collected. They have presented no data to suggest a disruption of equipoise and it must therefore remain. Any proposed treatment for EVD with no evidence of efficacy but a scientific basis for its use might cause harm just as easily as benefit and there are a multitude of examples from the history of evidence based medicine to remind us of this.

The authors state that none of them would have agreed to participate in an RCT of the investigational product zMapp. As a healthcare worker who is about to travel to West Africa and is therefore at some risk of infection I take the opposite view. I would refuse to take part in a trial of an unproven investigational product, either as a patient or investigator, unless it was as part of an RCT as I believe it would be unethical to do so. There was a limited supply of zMapp but if we had used 5 doses and performed a 10 patient RCT which dropped the death rate from 60% to 30%, we would have had a 42% chance of detecting the drug’s effectiveness. Instead we have missed that opportunity by giving it in an uncontrolled way. We now have no idea whether to move to mass production of zMapp as soon as possible or to push on with an RCT, and all the while people are dying.

The authors state that we use drugs with barely proven efficacy on cancer patients with a poor prognosis. This is indeed ethical if there is some limited evidence of efficacy and the prognosis is very poor. We can see a parallel in extremely drug resistant tuberculosis (XDR-TB) which has a similar if not worse prognosis than EVD2. While there are a number of drugs with phase 1 trial data, none are being given to patients outside of a trial setting. Only drugs with phase 2 evidence of efficacy such as bedaqualine are being used on a compassionate basis outside of RCTs.

The authors suggest that randomisation would be impractical and that patients could not be expected to offer informed consent. This is a patronising view of the people of West Africa. Informed consent based on the explicit knowledge that the doctors have no idea whether the treatment might be beneficial or harmful is definitely possible. Moreover it is very unlikely that any new treatment would be available in sufficient quantities to treat more than a tiny fraction of those affected by EVD. When a small supply of a novel drug becomes available how will it distributed? One hopes that it will not merely be offered to privileged foreign healthcare workers but be given to local patients in West Africa. An equitable and ethical way to distribute the drugs would be to offer entry to an RCT.

EVD is not so devastating that we should abandon RCT’s, in fact the opposite is true. We are duty bound to perform them whenever we can so that scarce resources can be channelled in appropriate directions once data arrives. Not to do so would be the unethical choice.

(1) Adebamowo C, Bah-Sow O, Binka F, Bruzzone R, Caplan A, Delfraissy J, et al. Randomised controlled trials for Ebola: practical and ethical issues. Lancet 2014 Oct 18;384(9952):1423-1424. (2) Pietersen E, Ignatius E, Streicher EM, Mastrapa B, Padanilam X, Pooran A, et al. Long-term outcomes of patients with extensively drug-resistant tuberculosis in South Africa: a cohort study. Lancet 2014 Apr 5;383(9924):1230-1239.