The first 30 days of thankfulness...

I started a Thankfulness project on Facebook 30 days ago. I'm writing down something I am thankful for everyday to take some time to reflect and by doing so, I hope it will give me a more positive outlook and maybe it can encourage other people as well. I thought it would be fun to compile the list and post it every month.

Day 1: I am grateful for my amazing family and time I have been able to spend with (some of) them over the past two months. Love you all to the moon and back - actually more - make it Pluto and back. (Yes, I know Pluto is a dwarf planet, but it's still further than Neptune.)

Day 2. Grateful for an extended (although unexpected) time in Holland, including wishing my niece a happy 5th birthday!

Day 3. Thankful for a safe and uneventful trip back to Freetown.

Day 4. Thankful for a fairly smooth first day with some chaotic moments and a heightened sense of caution but many welcoming colleagues.

Day 5. Thankful to know that "He is my Refuge and my Fortress".

Day 6. Thankful that one of my friends arrived in Sierra Leone this evening! It was fun to surprise her at the water taxi. Welcome back!

Day 7. Thankful for a lovely dinner at an Indian restaurant (Saffron) with the remaining Dutch contingent

Day 8. Thankful that I can sleep in a little bit tomorrow. Heading in to work at 9 am instead of 7:20.

Day 9. Thankful for a chocolate milkshake at Gina's. Definitely a perk when actually there for a work meeting.

Day 10. Concept note written for world bank funding - urgently need to make sure they or someone funds the Free Health Care Commodities (drugs etc) so that there is no stock out in January 2015! This is essential to ensure ongoing maternal, neonatal and child health care services in the entire country. Should get some feedback and then forward it on to the Ministry and they can take it from there.

Day 11. Thankful for King's Sierra Leone Partnership and the work they are doing at Connaught Hospital. I met some of the team yesterday and saw parts of their isolation set up/operations there. Great people doing a difficult job.

Day 12. Thankful to catch up with a small group of Dutch colleagues and meet one of the Dutch embassy people visiting from Accra headquarters.

Day 13. Thankful to meet up with friends and resume our 'International Bible Study Group' prayer time. Encouraging!

Day 14. Thankful for lab results - we finally got some results after days of not receiving any.

Day 15. Thankful for some time at Roy's restaurant on Lumley beach this evening.

Day 16. Thankful for a productive Saturday - lab packaging handed over to the lab staff at the hospital (to hopefully speed up delivery of specimens to the lab), meeting with one of the Welbodi Board members, talking about infection control in hospitals with a colleague and enjoying fast internet at Country Lodge.

Day 17. Thankful to spend the day at the beach with friends. Sun, Sea, Fish, Chips, Sand, Playing, Chatting. An all around good time with friends.

Day 18. Hmmm. Thankful for a yummy meal of pasta.

Day 19. Thankful for a good day although a very long one. Calling it a day now.

Day 20. Thankful I wasn't hurt (just a slightly bruised hip) when a vehicle backed into me from behind today on the hospital compound. And thankful for the nurse that pushed me to the side. Daily prayers for continued health and safety are welcome.

Day 21. Thankful for a friend who helped clean both Welbodi flats, which were a bit of a disaster after being empty for two months with this humidity. (I'm temporarily staying elsewhere anyway so I am not on my own)

Day 22. Thankful for a good Skype connection to communicate with our Director of Operations in the UK.

Day 23. Thankful for one of my friends and that I can celebrate her birthday with her today - heading to the beach later today.

Day 24. Thankful for an overnight trip to the beach. First time at Cockle Point.

Day 25. Thankful that the ODCH holding unit opened yesterday, starting with the transfer of suspected cases from the isolation area in the Emergency Room to the holding unit (support centre, donated by Cap Anamur, a German NGO, and they will also support the running of it), which is located on the compound next to the hospital with an access gate to the hospital compound. It has 3 wards for suspected cases (low, medium, high risk) I'm not directly involved, but may provide coordination support when needed. Two more patients were admitted today, of which one was a transfer from another facility. We have 4 patients with positive results awaiting transfer to a treatment centre (but the treatment beds are full). This is a positive step forward but there are still many challenges.

Day 26. I am so thankful for the email I received from a friend today saying that he is doing much better but still in Frankfurt recovering from Ebola. Thank God that he is beating this. Continuing to pray for his full recovery and release from the hospital (hopefully soon).

Day 27. Thankful it's bedtime. Feeling rather exhausted today. Praying for a good nights rest and a productive day tomorrow!

Day 28. Thankful that I was able to contribute to the International Child Health Group Winter meeting today. I joined the conference through Skype and provided the attendees with a brief overview of Welbodi Partnership and gave an update on the Ebola outbreak, recent developments and the many challenges. Afterwards there was time to answer questions from the audience. It was insightful and enjoyable!

Day 29. Thankful that people are finally seeing the importance of training hospital staff on infection prevention and control (IPC) so that they can safely provide regular care for non-Ebola cases. It's so important! Preliminary findings show that 60% of the health workers that have been infected with Ebola in Sierra Leone were infected in the non-Ebola areas of the hospitals, 20-25% in the primary care facilities, and the rest probably in either private practice, community settings, and Ebola units. I've been tasked to co-chair a committee with CDC focusing on training hospital staff in IPC.

Day 30. Thankful to have just made a teenager very happy by telling her she does/did not have Ebola. She was on her bed in the ward and I was standing in the visitor area within a 2 meter distance from the ward. She has been in the unit for 5 days and was eager to go home since she was no longer sick. I dropped off the discharge pack of clothes, slippers and transport money, so once she has showered she can head home. Mind you, for the next 21 days she will need to be monitored, in case there was any exposure in the unit. Praying she stays healthy!

Welbodi is recruiting: come and join me in Sierra Leone...

Welbodi Partnership is a UK-registered charitable organisation based at Ola During Children’s Hospital (ODCH) in Freetown, Sierra Leone. For the past five years, Welbodi has been working towards improved paediatric care and a reduced child mortality rate in the Western Area of Sierra Leone through hospital infrastructural development, staff training, and community engagement in partnership with ODCH staff, the Ministry of Health and Sanitation (MOHS) and the Sierra Leone Institute of Child Health (SLICH).

Welbodi Partnership will continue to support paediatric healthcare in Sierra Leone during the current outbreak of Ebola and is looking to recruit the following people to join the team in Freetown, Sierra Leone:

• (Paediatric) Nurse Educator
• Community Coordinator/Advisor
• Project Manager

Ebola has a big impact on the public health systems in the country and will lead to a higher morbidity and mortality from other illnesses. Many children will die during the outbreak due to preventable and treatable conditions such as malaria, pneumonia and diarrhoea. While measures to stop the transmission of Ebola are scaled up, there is a need to focus on supporting the hospital to safely provide routine paediatric services.

A partner organization is running an Ebola holding unit at ODCH, which enables Welbodi Partnership to focus on the hospital itself. Our main activities are:

• To support ODCH in strengthening the delivery of essential ‘routine’ health services (non-Ebola care) to children during the Ebola outbreak in a safe manner, by providing training (plus supervision and ongoing assessment) to hospital staff (nurses, doctors, cleaners, porters, laboratory technicians, etc.), with a primary focus on infection prevention and control (IPC); and by ensuring that IPC supplies and equipment are available to ensure a safe working environment. Thorough screening of patients prior to entering the hospital should decrease the risk of exposure of health care workers, but a degree of risk remains, making the need for strict infection prevention and control (IPC) protocols essential. Other training modules will be taught once the IPC programme has been implemented effectively.
• To provide ODCH with an Ebola Response Fund to meet immediate needs for the hospital during the outbreak for projects that have a direct impact on the Ebola response. The projects can relate to infrastructure, equipment & supplies and capacity building
• To play an active role in the Case Management Committee for the Ebola Response, chaired by the MOHS Director of Hospital and Laboratories, which reports to the National Ebola Response Team. This role involves providing input to Standard Operating Procedures (Holding Centres, Non-Ebola Care Units, Infection Prevention and Control, Ambulance/Transport systems, and more) rolled out at national level.
• To provide direct coordination support to the ODCH Ebola Holding Unit, supported by MOHS and a partner NGO, to ensure that laboratory results are obtained quickly and patients are transferred appropriately.

Once the Ebola outbreak stabilizes we will resume our core activity, which is to provide long-term health system strengthening. We will do this in collaboration with ODCH staff, the Ministry of Health and Sanitation (MOHS) and the Sierra Leone Institute of Child Health (SLICH) to address the infrastructure, equipment and capacity building needs of ODCH and surrounding PHUs by using a participatory approach at community, PHU and hospital level. We will also help establish and support training programmes such as in-country postgraduate training for doctors in paediatrics, a diploma course in paediatric nursing management and leadership and continuing professional development for healthcare workers.

We are currently looking for people to fill the following positions as soon as possible. Due to the urgency, applications will be reviewed as they are received and suitable candidates contacted on an on-going basis. All of the positions are for a minimum of 6 weeks, desirable is 6 months with the possibility of extension. Familiarity with Sierra Leone is a great plus.

Job title:	(Paediatric) Nurse Educator
Role:	To support the national nurse educator in the ODCH nurse training office and help ensure the continuous implementation of high quality in-service training for nurses. Initial focus will be providing IPC training and supervision and monitoring on the wards to healthcare workers (nurses, doctors, cleaners, porters, etc.).
Requirements:	Minimum: A recognised professional nurse qualification with additional qualification in paediatric nursing or infection prevention & control or education, with at least 2 years of experience.
Desirable:	Experience of nursing and/or teaching nurses in West Africa.

Job title:	Community Coordinator/Advisor
Role:	To assess the current needs in the communities and Peripheral Health Units (PHUs) in the vicinity of ODCH in terms of social mobilization in the Ebola response as well as access to and availability of child health services. Long term: To support women and children by engaging community groups in participatory learning and action cycles to identify and prioritize challenges in accessing quality care and addressing these issues at community, PHU and hospital levels.
Requirements:	Minimum: Graduate level degree in relevant field or minimum 3 years health sector and project management experience.
Desirable:	Community or project management experience in a developing country.

Job title:	Project Manager
Role:	To manage projects at community, PHU and hospital level approved by the SLICH Board or a designated sub-committee that have a direct impact on the response to Ebola and neonatal and child health. This includes managing financial and material resources as well as ensuring that project objectives and outcomes are well designed, monitored, evaluated and met. To reconvene and facilitate quality improvement groups in facilities when this is feasible and appropriate.
Requirements:	Minimum: Graduate level degree in relevant field or minimum 3 years health sector and project management experience
Desirable:	Project management experience in a developing country

Benefits

We are looking for people to join the Welbodi Partnership team in Freetown as soon as possible. Benefits include a return flight to/from Sierra Leone, cost of visas and residence permits, cost of national professional registration, shared accommodation, emergency medical and travel insurance (including evacuation), transportation to and from work and a monthly stipend. A good command of the English language is required. Flexibility in roles and responsibility is essential. Appropriate training will be provided on arrival in Sierra Leone and personal protective equipment will be provided on site.

Application process

Interested candidates should email a copy of their CV, cover letter, and a list of three relevant references to jobs@welbodipartnership.org as soon as possible. The job title should be included in the subject line. We welcome applicants of any nationality, including Sierra Leoneans at home or in the diaspora. Only those applicants shortlisted for an interview will be notified.

Your cover letter should include:

• Your country of residence and nationality
• Your date of birth
• Dates you are able to commence
• Duration of availability

Ebola: The reality as Freetown and outskirts hit 1001 cases...

It seems as if an hour doesn't go by without Ebola being a part of it. Whether it is during a conversation, work at the hospital, a radio programme, an advertisement, a bucket of chlorinated bleach outside a restaurant, an ambulance with driver in a protective suit that drives by, the constant thought of not touching one's face, no personal contact, a billboard etc. Ebola has become entwined with daily life. Strangely though, when driving through Freetown things still feel fairly normal. It's a bizarre situation. 

Sadly, the situation in Freetown is getting worse with today's report revealing 1001 confirmed cases in the Western Area district (Freetown and outskirts). It is concerning that this might be the tip of the iceberg since it only includes cases reporting to a health facility. Since isolation beds are full, sick people are often turned away at the gate and forced to go back home meaning they aren't tested for the disease yet and they can further spread Ebola at home if that is what they have. As beds open up, sick people are transferred to a facility or someone waiting outside the gate may be lucky to get in. In an overcrowded urban setting, numbers are going to increase exponentially. I fear that Ebola will not only be a continuous part of daily life as people take precautions, but it will become a real life event for many people who will lose family members and colleagues to this dreadful disease, not to mention to other diseases due to the lack of healthcare in the country at the moment. In contrast to the USA, where the chance of someone knowing a person infected with Ebola (much less die of Ebola) is very small, for people in Freetown, the likelihood is far greater.

At the Children's hospital on Friday we received results back from the Ebola lab and had to transfer three confirmed Ebola patients to the treatment centre in Hastings. Two were mothers whose children died in the isolation unit in the hospital earlier in the week. And the third was a little boy who was admitted to the isolation unit 9 days ago. The ambulance arrived and while hospital staff put on full protective suits to escort the mothers to the vehicle, a father walked with his son in his arms from the isolation unit to the ambulance. It was heartbreaking to watch the father lift his 6 year old son into the back of an ambulance not knowing if/when he would see him again. I cannot imagine what he was feeling. I felt sorry for one of the ladies who looked terrified as they were lifting her in. She has already lost her toddler and now she was being taken to a place she does not know or understand by people in full protective suits. 

On Friday I witnessed the impact of Ebola on three families, but many more families out there will experience similar tragedies. Unfortunately the case numbers seem to be increasing at a faster pace than we can contain it. Efforts are being made to improve contact tracing, case identification, case management (isolation, testing, treatment) and dead body management (safe burials) but it is complex.    Basically we need to achieve 70% safe burials and 70% isolation nationwide to see transmission reduce. I hope that somehow the situation will start to improve with more relief efforts on the ground and we will begin to see a decline in numbers. I just feel like we don't have much time to wait! Thankfully in the East of Sierra Leone cases have decreased from a high of 50 per week to 4 per week. 

Welbodi Partnership’s Emergency Ebola appeal...

I waited with this appeal until there was some more certainty as to how Welbodi Partnership will continue its response to the Ebola outbreak. We have a small team of national staff on the ground and I plan to return to Freetown soon to resume my role with Welbodi at the Children’s hospital.

I will spend the first week doing a needs assessment, discussing with hospital staff and partner organisations to see what the needs are and how Welbodi can help fill some of the gaps. This may include coordination and logistics and making sure that ‘general’ medical care can be provided to children who do not have Ebola, while ensuring staff safety. At the same time we want to work towards a long-term goal of health system strengthening – improving standards at the hospital to improve the quality of health care delivery and so that outbreaks like this can be prevented and contained in the future.

We simply cannot know with certainty what will be needed a few days from now, let alone months down the line, as Sierra Leone works to contain and then recover from this outbreak. What we do know is that the principles by which we have always operated—particularly the principles of partnership, and our recognition that health facility staff are often the best judges of what kinds of support they need—still hold during this emergency and its aftermath.

We are therefore raising an emergency fund to support initiatives proposed and implemented by staff on the ground. We will work with staff to develop and implement these ideas, and will coordinate with the MOHS and with other NGO partners, particularly those with expertise in Ebola prevention and control.  We envision that these initiatives might include efforts to train health personnel in infection control, provide protective equipment, improve the waste management system, provide other supplies needed to promote infection prevention on the wards or in areas such as the laboratory and pharmacy and contribute to the general improvement of the hospital. In the long run, there will be a great need for strengthening health systems and rebuilding trust in the health facilities and among communities.

We would be grateful for your support—whether by donating funds or spreading the word. You can donate online here, or contact us to find out how you can help.

Thank you.

Ebola: Sierra Leone's Ose-to-Ose campaign & "lockdown" end...

A few hours ago I received a report from the Ministry of Health and Sanitation, Emergency Operations Centre (EOC) in Sierra Leone - the Ebola House to House Sensitization Campaign is officially over. After 3 days of lockdown, people are no longer confined to their homes. There was a discussion about extending the lockdown since not all of the houses were reached, but it was decided to end the official lockdown and continue the house-to-house social mobilization exercise in the hot spot areas around the country.

It's hard to know how successful a campaign like this was. It sounds like 75% of the households were reached nationwide, which sounds like a reasonable percentage in a 3 day period to me in a country with over 6 million people. Besides one incident in the East of Freetown, the nation was peaceful, which says a lot about people's willingness to cooperate and some trust in the government. From what I have heard, the quality of health talks varied but that's to be expected with over 21,000 volunteers with varying backgrounds and very recent training. I have heard that in some homes a bar of soap was given but little information about Ebola itself was provided and no questions were asked about sick people on the compound. In other homes, talks were more extensive and sick people were identified and taken to holding units. Hopefully overall, awareness increased. Although the main aim was raising awareness, suspected Ebola patients were also identified and dead bodies were also discovered. Of course, not all of the deaths will be due to Ebola.

The campaign is over but the outbreak is not. It is important that the general public realizes this. There are often strange beliefs and already I have heard that some people think that Ebola is now gone. Also, a message was sent around today by a Bishop urging all citizens to call on the name of Jesus at 6 pm this evening to 'kick Ebola out'. From friends in the city, I heard that at 6 pm they did hear loud cries of 'Jesus, Jesus, Jesus'. Some people may well believe that this is all it takes. And while I believe that divine intervention is possible, I also believe that people need to be wise and sensible. Giving people hope is good, but not if it leads to people being careless. We need people to continue taking this disease seriously and move forward with extreme caution. There are still many challenges with sick people being too afraid to go to health facilities, health care workers not feeling protected enough to work, lack of beds in isolation/holding units and treatment centres, lack of staff, etc. It is also good to remember that many more people are now dying of diseases such as malaria, typhoid and pneumonia than they are of Ebola due to lack of general health care. There is still much to be done.

Hopefully this campaign was a step in the right direction...

Ebola: Ose to Ose Ebola Tok...

Today marks the start of the nationwide House-to-House Family Sensitization on Ebola Campaign in Sierra Leone. The campaign is entitled 'Ose to Ose Ebola tok' and is scheduled for the 18th - 21st of September. Three of these days (19th-21st) will be stay at home days for the entire population, except for health care workers and those sensitizing the public.

The main objective is to reverse the trend of new Ebola cases as well as to enhance interpersonal communication and engagement of communities in the fight against Ebola. In total 28,544 (7136 teams of 4 people) will be mobilized across Sierra Leone. 

While the situation continues to worsen in Sierra Leone, it is important that communication is clear and people work together to fight Ebola. Let us hope that these days will be effective and that more people will come to realize  how real Ebola is and what needs to be done to break the chain of transmission.

Let us pray for peace in the country. The fact that people will need to stay at home for 3 days straight can pose many challenges. For some, it will be difficult to ensure that there is enough food and water available in their household. Pray for God's provision for these people and that this will not lead to any rioting. Pray for cooperation and understanding amongst the general public and for wisdom and protection of those leading and participating in the delivery of this campaign.

The impact of the Ebola outbreak on child health in Sierra Leone...

The worst Ebola outbreak in the world is confirmed to have infected 1,305 people in Sierra Leone to date¹ though the actual rates may be higher. Of the Ebola confirmed cases, around 22% are children between the ages of 0 and 17 years². Children are not only getting infected with this disease, but many have either been separated from their parents or been orphaned due to Ebola and many more children can no longer access basic health services for non-Ebola illnesses.

The loss of over 240 healthcare workers due to Ebola infections in the affected countries of Sierra Leone, Guinea, Liberia and Nigeria, with long-standing shortages of healthcare professionals, has understandably instilled fear amongst hospital staff and has led to a demand for more training, sufficient protective equipment and incentives before they feel confident to proceed with their work on the front line. This, in combination with a fear amongst the general public to report at health facilities and the difficulty in identifying suspected cases when reliable histories are not forthcoming, has resulted in many health facilities closing or only running outpatient services. Amongst these health facilities is the Ola During Children’s Hospital (ODCH); the only government run Children’s hospital in the country, which is now temporarily closed.

At ODCH, which Welbodi Partnership has supported for over 5 years now, preparations were made in collaboration with hospital staff and partnering organisations at the start of the outbreak for the possible arrival of suspected Ebola cases. This included setting up a small isolation unit, ensuring the availability of personal protective equipment in the unit, training of staff and screening of patients at the entrance of the hospital. It also involved the reinforcement of using universal precautions on all of the wards.  

The screening questions are based on the case definition for Ebola, which includes specific symptoms, travel to/from an affected district and contact history with an Ebola patient.  Since the transmission of Ebola is through contact with bodily fluids of an Ebola patient, the contact and travel history are important. It is estimated that prior to the outbreak, 80-90% of children presenting to hospital come with symptoms such as fever, diarrhoea, vomiting, and weakness; symptoms that not only categorize Ebola, but many other common diseases such as malaria, typhoid and gastroenteritis. If the case definition were only to focus on symptoms, this would mean that the majority of children presenting to the hospital would need to be isolated, which with approximately 1000 admissions a month at ODCH, would be a daunting task. It would require a rapid turn around of laboratory results and a large medical and logistics team on the ground, as frequent entry into the unit would be required to assure that infants and young children are receiving adequate hydration and care, particularly as it is not guaranteed that these children could be isolated with a dedicated caregiver.

The agreed procedure at ODCH in dealing with suspected Ebola cases was put to the test in early August: a child arrived at the hospital and was screened at the entrance. The history revealed fever, vomiting, weakness and a positive contact and travel history. Since the patient met the case definition, the child was immediately isolated in the hospital’s isolation unit while testing was carried out. Two days later when the test result came back positive, the child was taken to an Ebola treatment centre in the east of the country. All staff that came into contact with this patient were aware that she very likely had Ebola and took the necessary precautions. Although this case brought up a few challenges in the process, it did go according to plan and the hospital continued with the same procedure.

Only a week later, however, another child arrived at the hospital. This child had symptoms of fever, diarrhoea and vomiting, but the father denied any history of contact with an Ebola patient or travel from an affected district, most likely because he was afraid to hear that his child might have Ebola. For many, the diagnosis of Ebola is seen as a death sentence. Since the father withheld essential information, the child did not meet the case definition and was admitted to the Emergency Room. It was not until two days later that one of the doctors found out from another relative that the child had been in contact with an Ebola case. Alarm bells rang and preparations were immediately made to transfer the child to an isolation unit for testing for Ebola. All other patients were moved onto another ward and the Emergency Room was decontaminated.

As one can imagine, hospital staff was nervous, having cared for this patient for two days on a general ward, using gloves and universal precautions, but not using the full protective suits since the patient was not admitted as a suspected case. It was decided that all staff in direct contact with this case, would be quarantined in their homes where they would sit out the 21-day incubation period with the hope that they had not been infected.  Since that day, ODCH has been closed to new admissions, because without reliable histories during screening it is impossible to identify a suspected case and isolating all cases arriving at the hospital was an impossible task due to size limitations of the initial isolation ward. Over the next few days, most children were discharged from the hospital. Two days later, the result for the child was announced: positive.

Thankfully, 21 days has passed and none of the staff that came in contact with this case have shown any signs of Ebola, but to date, ODCH, the country’s only government-run paediatric hospital, remains closed.

This story is not unique. Many health facilities across the country and in the sub-region are in similar situations. The impact of this outbreak on the already fragile health systems throughout West Africa will be immense. On average, ODCH admits 1000 patients in the month of August. The fact that ODCH was shut for the second half of the month means that 500 children who would normally have access to health care services, did not. What is the fate of these children? Children with diseases such as malaria, pneumonia, gastroenteritis and other common diseases may well die. The implications will also be severe for services such as outpatient paediatric HIV/AIDS and tuberculosis treatment, as these patients are either afraid to come to the hospital to receive their medications, or health staff are placed at high risk without proper protective equipment to allow them to safely conduct consultations. The immunization programmes will be hindered and many children may not be immunized adequately during this outbreak. It is fair to say that we will see an increase in both morbidity and mortality over the next months. Extrapolating data from a Lancet article in 2013^3,4 it is estimated that 2,500 women and children die in Sierra Leone every month. With the current strains on the health care services this number is inevitably going to increase, and this will never be accounted for in national Ebola mortality statistics. The closure of the hospital has also had an impact on the few remaining health facilities in the area, already overburdened by the demands of the Ebola outbreak, and with limited experience in paediatric care.

Efforts are underway to re-open the hospital, but this must be done in such a way to ensure the safety of both staff and patients. An effective screening method needs to be put in place so that the hospital is not, once again, forced to close. With a high level of fear amongst the general public, it could be that other caregivers will not be forthcoming with the actual history, for fear of their child being isolated. Finding a safe way to re-open the hospital potentially means that a large proportion of children presenting to the hospital will need to be isolated and tested prior to being admitted, since the symptoms of Ebola mimic that of other diseases. NGOs currently on the ground at ODCH are working with hospital staff, the Ministry of Health and Sanitation and other agencies to discuss plans to set up a larger isolation unit adjacent to the hospital for this purpose. In the meantime, training of hospital staff is ongoing with a big focus on infection control measures, including the use of personal protective equipment. Welbodi Partnership is currently providing advice from afar but hopes to return soon to support the efforts at ODCH.

In itself, Ebola is a terrible disease, causing suffering and death, but the impact on the fragile public health systems in the country means that the morbidity and mortality from more common illnesses will be on the increase. Measures to stop the transmission of Ebola need to be scaled up to control this outbreak.  At the same time, and continuing into the future, the current health systems need to be strengthened to ensure the availability of high quality health care in Sierra Leone, as well as to prevent and control such outbreaks in the future.

¹ MOHS Sierra Leone Situational Report - 9 September 2014 http://health.gov.sl/?p=537
² UNICEF Sierra Leone - Ebola Virus Disease - Weekly update (1-7 September 2014)

³ http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60497-9/fulltext

⁴ http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60696-6/fulltext

Written by: Sandra Lako, Welbodi Partnership

Ebola: The current situation...

As of the 9th of September 2014, the number of people that have been confirmed to have the Ebola Viral Disease in Sierra Leone is now 1,305. Of those, 893 of the cases are in the two districts of Kenema and Kailahun in the east of the country and 118 of the cases are in the Western Area district, which includes the capital city of Freetown. The rest of the cases are scattered all across the country in all but one district, Koinadugu, the only district with no known Ebola cases.

The situation is getting worse. These numbers are bad enough, but I am certain they are just the tip of the iceberg. The cases mentioned are those who have had laboratory testing, in other words, those who have presented at a health facility. The issue is that many people are not presenting to health facilities. They are either too scared to go for fear of being isolated or contracting the disease, likewise, health care workers are afraid to work for fear of becoming infected. 

All this to say that the numbers reported are likely to be a gross underestimation of the actual situation. There are probably hundreds if not thousands more Ebola cases throughout the country. Many people are sick and dying in their homes, and while suffering they are at the same time spreading the disease to other family members. It is a sad situation.

And now, even if patients want to access healthcare, many health facilities are shut and even the Ebola treatment centres in the country are currently full. This provides a signifiant challenge. The few holding units (isolation centres) in the country that are isolating and testing patients now have nowhere to send their positive patients too. This means that their beds are full and new patients cannot be admitted for isolation and testing. This means that patients are forced to go back into their communities, which leads to further spread of the disease.

The only solution to this problem is to set up more treatment and isolation units across the country, which asks for a strong human resource and logistical commitment from both the government of Sierra Leone, partner organisations and the international community at large. 

There are plans to set up new isolation and treatment centres, but unfortunately it has proven to take weeks, if not months, for these centres to be functional. What will happen to those with Ebola in the meantime and how much more will this virus spread before patients can be properly isolated, tested and treated again? 

I know that both the US and UK governments have agreed to help with setting up (and possibly running?) treatment centres in Liberia and Sierra Leone? But will the proposed 25 and 62 beds respectively be enough? I think the answer is obvious. The international community and the government of Sierra Leone need to scale up their efforts considerably. It is already expected that thousands of additional cases will surface in the next few weeks. What happens next?

Ebola: The World's Response...

While sitting in The Netherlands after needing to leave Sierra Leone just over a week ago, I am not only pondering when and how I can go back to support the fight against Ebola but I am also reflecting on what the world's response is and should or could be during this current outbreak. Yes, there has been some response from leaders world wide, but is it adequate and appropriate?  Recent articles from The Guardian and New York times state that not enough is being done. Who should respond and what should that response look like?

In the initial phase of this outbreak, I think the disease could (should) have been contained and dealt with by the governments of the West African nations, with strategic support from experienced agencies such as MSF (Doctors without Borders), CDC (Center for Disease Control), Public Health England/Canada and the WHO (World Health Organisation). There are so many factors that have contributed to the fact that the situation is now out of control. I personally feel that more could have been done. Sierra Leone, for example, could have shut the borders to Guinea and Liberia immediately, districts such as Kailahun (and Kenema) could have been quarantined in a very early stage of the outbreak, training of health care staff and mobilisation of resources throughout the country could have been completed prior to the spread of the disease, enhanced security could have been enforced at isolation and treatment centres and a state of Emergency could have been declared weeks before it was. But this did not happen. Some of these measures have since been put in place, but is it too late?

Now, due to a variety of reasons, we have an outbreak, with 783 confirmed cases in Sierra Leone as of the 19th of August (MOHS statistics), that is seemingly impossible to contain. I do not think that the governments can solely be blamed for this, the behaviour of citizens has definitely played a role as well. 

Based on past experiences, many Sierra Leonean citizens did not trust the government or health care workers at the start of the outbreak leading to both a disbelief in the existence of Ebola and a lack of cooperation with health care professionals and government officials. This meant that high-risk cultural practices (such as washing bodies before a burial) continued to take place, confirmed cases escaped treatment centres or were pulled out by their relatives, patients were hidden in their homes and contacts of cases did not come forward. 

Various conspiracy theories concerning the origin of the outbreak added fuel to the level of distrust. Some people believed that Ebola was a way for the governing party to wipe out those in favor of the opposition party (the districts in the East). Others believed it was just another way for the government to gain foreign aid; a way for the rich to get richer with the thought "more cases = more aid". Some believed that the 'white man' introduced Ebola to wipe out Africans or to come and test their drugs. Some thought that health care workers were injecting people with Ebola. There are so many theories that have made it difficult to deal with this outbreak quickly. Rumors of remedies such as bathing in salt water or drinking special water sent by a Nigerian pastor have also compounded the matter.

Now, I think most people believe that Ebola is real. But are people informed enough? Do they realize the scope of the problem? Do people know what to do or not to do? Is the fear of Ebola going to keep sick people at home? 

People are afraid that if they go to a health facility they may contract Ebola from a doctor or nurse. Even for those that want to access health care, the situation has worsened to the extent that the health care system has basically collapsed. Due to fear of contracting the disease from patients or lack of protective equipment or colleagues succumbing to the disease, many health care workers are too afraid to work. Some hospitals are refusing new admissions and have basically shut down. What does that mean for someone with a fever seeking medical care? They may be turned away at the health facilities and forced to self treat at home for disease such as malaria or pneumonia. They may or may not get better. They may die at home of Ebola, meanwhile infecting their family members. People are afraid that if they have a fever and go to a hospital, they will be isolated immediately and be tested for Ebola. They fear they may be isolated with other people that may be positive for Ebola and they might even catch Ebola while waiting in an isolation unit. They are afraid that if they are positive they will be taken to a treatment centre, which for many, is seen as a death sentence. These are all realistic fears that need to be addressed.

The ripple effects of the outbreak include a collapse of the already fragile health care system leading to more men, women and children dying at home from preventable and treatable diseases. The outbreak has temporarily suspended formal educational systems and will have serious economic impacts as well, with a loss of trade, less investments and reduction in farming.  Fears now are that people may struggle to find food and that the risk of starvation may surface.

It is obviously time for a global response. International support is crucial. Governments from around the world need to work hand-in-hand with the governments of West Africa. Global leaders are needed to help with decision making on solutions to overcome this outbreak. 

However, according to The Guardian, "The international community has made "almost zero" response to the Ebola outbreak in west Africa, with western leaders more interested in protecting their own countries than helping contain the crisis that has now claimed more than 1,200 lives, a senior international aid worker said on Tuesday. "Leaders in the west are talking about their own safety and doing things like closing airlines – and not helping anyone else."

Is that the response the World is ready to offer? Or will they look beyond their borders and realize that their response needs to be directed to what is happening on the ground in West Africa? 

The operations director of MSF (Doctors without Borders) states that "the solution is not that complicated but we need to have political will to do so. Time is running against us. But you need very senior people with high profiles, the kind of people who can co-ordinate a response to a million people affected by an earthquake," he said. He also said containing Ebola was "not rocket science" identifying "contact tracing" and public communications as the key factors.

Can the world deliver this? I hope so because otherwise this fight seems very hopeless. 

Practically speaking, more doctors and nurses are needed to run treatment centres and isolation units across the country. There simply are not enough medical professionals in country to deal with this situation. Mobilisation of resources are needed to make sure that every health facility has the PPE (Personal Protective Equipment) they need - full PPE suits for isolation and treatment centres, and enough protective gear (gloves, aprons, masks, eye protection) on the wards of every hospital and health centre to enhance infection control measures. Training is needed to ensure that people use the protective equipment appropriately and do not infect themselves when taking it off for example.  People are needed on the ground to support contact tracing and surveillance systems. People are needed to go from house to house to follow up on those who have been in contact with Ebola patients. Coordination is needed to support all of these efforts. Communication needs to be effective. Unless this happens, the disease will continue to spread. It's time to work together, it's time for a global response. 

Dr. Liu, President of MSF said that "no matter how many patients her organisation treats, the outbreak will not end until other agencies can halt the progression of new infections."

This is a call for help from West Africa to the rest of the world. This is a please for individuals, organisations and governments to join the fight to end this outbreak. Who will step in?


Quotes taken from: 
http://www.nytimes.com/2014/08/20/world/africa/ebola-is-disaster-of-scale-still-unknown-relief-official-says.html?_r=0
http://www.theguardian.com/society/2014/aug/19/western-leaders-ebola-outbreak-africa-medecins-sans-frontieres