Alumni Profile: Ahmed Seedat and the Importance of Building Relationships

I initially volunteered with KSLP as clinical lead from September 2013 to March 2014, having spent the previous six months volunteering with VSO (Volunteer Services Overseas) in Sierra Leone.

Amed SeedatIn those early days it was just Oliver and me, shortly joined by Suzanne, so our roles were a little more fluid and we had a bit more space in the office!

My role mainly involved supporting the Connaught Hospital Improvement Committee, particularly in strengthening the Accident & Emergency Department, supporting colleagues at COMAHS in delivering teaching and training for undergraduate medical students as well as working on postgraduate training with a focus on strengthening the internship programme.

I returned to Freetown in August – September for the Ebola outbreak.

Back in the UK I’m a Respiratory Registrar trainee based in South London but left for an OOPE (out of programme experience) in November 2015 – I managed to stay in the UK for just over a year!

Currently I’m in Yida, Unity State, South Sudan working as a medical doctor for MSF. In Yida, MSF are providing medical care for the refugee population affected by conflict in South Sudan and the disputed South Kordofan region.

Although the context is very different requiring a different approach and perspective I find that as with KSLP, relationships between national and international staff, the wider community and other key stakeholders are extremely important. This can be less than straightforward in an unstable region or area affected by conflict. Nevertheless, building relationships particularly with colleagues and the local community lays the foundations for trust, mutual learning and knowledge exchange which is not only helpful for us as individuals but hopefully translates into wider health gains for the local population.

A Passion for Nursing – Connaught Hospital Matron Isatu Kamara

Since she was a little girl she had Connaught Hospital relies on its team of dedicated nurses to keep functioning. Isatu Kamara, or as we all know her as “Matron,” has been at the helm of this team since 2014.

Since she was a little girl she had “the passion to become a nurse.” She started her career as a Registered Nurse at Connaught so she knows all the “nooks and crannies of Connaught.” She left Connaught to continue her career working in Kambia Government Hospital, Ola During Children’s Hospital, and Kabala Government Hospital. Before returning to her home at Connaught, she had been the Matron of Kenema Government Hospital for three years. She uses her extensive managerial and technical experience to ensure that the highest quality of nursinc care is available to all patients. 

When asked if she has advice for future nurses, her answer is that “you should be willing to perform, you should have the capacity to perform and have the opportunity to perform.” A strong enabling environment is particularly important to Matron who explains that “if we have the basic equipment, skills and motivation then the enabling environment is there for nurses to perform.”

Matron is very proud of the recent changes to the hospital, especially the cleanliness of the wards after the recent IPC training that has been conducted. “Connaught Hospital is such a different place, I encourage all people, partners and staff to make the most of the facilities available such as the Oxygen factory, the A&E Department and the Infectious Disease Unit.

Reflections from the Intensive Care Unit – Ruth Tighe

I graduated from Nottingham Medical School in 2004 and after many years out exploring countries and specialities, I finally decided on Anaesthetics/Intensive Care Medicine.  In the past most of my experiences working abroad have been aimed at improving my clinical skills, to ensure I have been exposed to extreme cases to hopefully make me a better registrar.

I would have always claimed global health was an interest but until January 2015, I wasn’t planning to adventure out to Africa again until I’d become a consultant.  But then the idea of Sierra Leone came up via one of my best friends, Ling – Emergency Co-ordinator for the King’s Sierra Leone Partnership and I couldn’t resist.

I chose to work with King’s because it proposed a unique way of developing intensive care in a low income country that has no post-graduate training and less than 5 anaesthetic doctors in country. The King’s approach thinks more about the system and the professionals you are working with rather than your own skill progression.  King’s encourages a gentle approach via role-modelling for staff working in the main governmental tertiary hospital, to instil comprehension and propagate behaviour patterns that will continuing after I’ve left. Essentially it is about being incredibly patient, building relationships, and working together to spot holes in the functioning of the Intensive Care Unit. Most solutions are achieved without huge changes in practice; the focus is rather on training, education, and monitoring outcomes to demonstrate efficacy.

Although we are mostly volunteers, we are trying to tackle large-scale projects to impact on the entire health system. One of my first tasks as Critical Care Co-ordinated was to support the ICU to improve the provision of oxygen in Connaught. My first four months were focused on the development of the first fully functioning oxygen factory in the country. The results have been impressive. In the three months since we got the first piped oxygen in the country, we’ve seen mortality drop by nearly 30%.  My dream is that my colleagues and I can start a program that shares our experiences with the five non-functioning factories in the districts so that all of Sierra Leone would have access to simple oxygen therapy. Our next project is to implement non-invasive ventilation and again hopefully see another fall in mortality and potentially expand this out to districts. It is incredible to work in a system where simple changes can produce such a drastic change in outcomes.

While I’m not necessarily getting awake fibre-optics or ECMO experience, I am getting more teaching, management, research, and quality improvement opportunities than I thought possible. Being passionate about this cause easily motivates me to work hard to get one project finished so I can start the next one.

Sierra Leone has been through a lot, yet there is an overwhelming sense of gratitude that they’ve come through the war and Ebola. Everyone here has such a strong faith, which is probably what holds them all together through such tough periods.

My respite is knowing I get weekends surfing at Bureh Beach – every week by the time Friday comes I’m so excited to get back in my new-old defender and bounce along the coast, hang out with friends to attempt to stand on my foamie board in the white water – it washes away any stresses from the previous week and gets me refreshed for the next.

I’d be lying if I said this wasn’t stressful.  Witnessing the poverty and the needless deaths of people who can’t afford their health care is extraordinarily draining. But any time it starts to break me, I reflect on our wonderful NHS (long may it last!),  and that I am lucky to be healthy, to have received a full education, and to be trained in a job that I love that lets me travel the world!

Strengthening A&E at Connaught

On 21 October, the Minister for Health and Sanitation, Dr Abu Bakr Fofanah, visited Connaught Hospital to discuss plans for the refurbishment of the Accident and Emergency (A&E) Department.

A&E is an emerging area of specialist practice in Sierra Leone with potential to transform how health care is delivered in the country. Connaught staff have been working with King’s Sierra Leone Partnership to reform how A&E care is provided. Recently the hospital has successfully implemented a new triage system to prioritise the urgency of patient treatment.

The refurbishment includes the construction of a dedicated minor procedure room so that staff can conduct urgent surgeries within the A&E department.  There will also be new water and sanitation facilities for hand washing, improved waste disposal provision, and drainage to support improved infection prevention & control processes.

Through the improved capacity of the A&E department, Connaught Hospital will be better able to respond and prevent future health crises such as ebola, as well as manage casualties from other health emergencies.

Technicians at Connaught

We would like to introduce Ibrahim, one of Connaught Hospital’s highly skilled technicians behind the functioning of the hospital’s new oxygen factory.

Since the rejuvenation of the oxygen factory he says, “I feel more secure in my job and that my team are needed and will continue to be supporting the hospital in the future.”

Ibrahim first started working at Connaught Hospital 5 years ago. Since then he has become a specialist in handling medical equipment like ECGs, monitors, anaesthetic machines and, of course, oxygen concentrators. Ibrahim enjoys his job and is always looking to improve his skills. He and all the technicians are hoping that in the future they will continue their training so they can maintain the full range of specialised medical equipment needed at Connaught.

Ibrahim is very positive about Sierra Leone’s future. “So many sad things have happened but we are strong people. Ebola exposed weaknesses in health care so we are improving from now.”

An Engineer in Freetown

My name is Gerard Dalziel and my title here is Volunteer Site Engineer for Connaught Hospital, Freetown Sierra Leone. I came to volunteer with KSLP through Engineers Without Borders in February for a six month period. On any given day the duties can range from repairing a centrifuge to consulting with the Sierra Leone Fire Brigade for a fire safety assessment of the hospital wards.

The Site Engineer’s major function is to assist in the planning and in preparation of contract documents to refurbish and or re-purpose portions of the hospital campus for the post-Ebola rebound of the Freetown health care system.  The international community has realized that the weakness of the health care system was one of the causes of the severity of this particular epidemic, and is therefore determined to put the resources here to bring the health care facilities up to a minimum standard of infectious disease prevention and care (IPC) so that the system is better prepared for the next epidemic.

We are currently in the process of building a new chest clinic where patients with a range of illnesses, particularly TB, can access care, along with HIV counselling as this is a frequent co-morbidity. The building had been abandoned for some time so was not in a good condition, but we’ve recently completed it and it now looks very smart.

We have also just completed a new safer structure to house the hospital oxygen generation factory, which was previously unusable because the structure it was in was too small to prevent overheating. We are also upgrading the oxygen delivery system with portable tanks and oxygen concentrators to support a CDC trial of a new Ebola vaccine.

Next week we will be putting the construction of a new infections disease (ID) holding unit out to bid, so that what is now being used as the Ebola holding centre can go back to its previous purpose.  After that we will be planning a possible campus expansion to add additional ID capacity to the hospital.

Part of the reality of the work here is the on-going struggle to eradicate Ebola from Freetown and from Sierra Leone in general.  You wash your hands in chlorinated water every time you enter the hospital grounds in addition to rinsing them off with alcohol gel several times a day.  The Ebola holding unit is near the front entrance of the hospital and is occupying what used to be the emergency area of the hospital.  Post-Ebola, the old holding centre will be upgraded to a new Accident and Emergency Department (A & E) with the addition of new patient treatment capabilities.  My work is therefore linked closely to King’s other projects, in this case providing ongoing mentoring and support for staff on Emergency Medicine, through expert volunteer medics from the UK.

In order to plan for the future A & E Department, we had to measure the dimensions of the existing holding unit.  I was able to measure the outside of the building in partial personal protective equipment (PPE) but trained medical staff had to take the inside dimensions in full PPE.  The tape used to measure the inside was incinerated with other medical waste as possibly being contaminated.  This is one small example of of how Ebola has affected how we do our work here.

The volunteer medical staff from Kings Hospital in London and the in-country Sierra Leonean staff are extraordinarily determined to eradicate Ebola and to come out of this crisis stronger and better prepared to to meet the future health care needs of the city.  I hope to continue to share in that work by lending my engineering skills wherever needed.

Developments in Mental Health at Connaught Hospital

I joined the King’s Sierra Leone Partnership (KSLP) team as a volunteer Doctor in February 2015. Like most people, I had followed the news about Ebola, particularly the devastating effects it was having on Sierra Leone and its people. Having been born in Sierra Leone, the events were particularly personal to me. I moved to the UK when I was 6 years old, but have many links to the country with family and friends still living there and many fond memories of my childhood.

As a Psychiatry trainee at South London and Maudsley NHS Foundation Trust, I hoped to be able to provide not only physical health care but also psychosocial support to those affected. I was keen to come out to support colleagues, both local and international, who had been working tirelessly to control the outbreak. The process of being released from my training programme was straightforward and I was granted a 6-month sabbatical.

This patient reminded me of the importance of good mental health care and how integral this is to any healthcare service. Had his mental illness been identified and treated earlier , his compliance to medical treatment would have been better and therefore more successful. His sister explained that he had been a professional with a well respected job; however, over the last year his mental health had deteriorated. The family had been unable to access appropriate care. She seemed to have reached the point of exhaustion having been the sole person to shoulder the burden of caring for her only brother, and she was comforted by the thought that at least he would no longer suffer.

I found myself in a challenging situation: I had volunteered to be an Ebola outbreak Doctor, albeit one with specialist mental health skills that I was sure would be useful in helping patients affected by Ebola. However, faced with a reducing numbers of cases and a clear and acute need for mental health care, I felt increasingly driven to giving my time to those with mental health needs. I recalled the WHO slogan ‘no health without mental health’ as I contemplated a change in the focus of my work.

I shared my sentiments with Oliver Johnson, KSLP Programme Director and was enthused by the support he expressed for me to do more direct mental health work. Mental health is a priority for KSLP, and one of the key areas in which they have been  making great strides . Prior to the Ebola outbreak, Katy Lowe, a mental health nurse from South London and Maudsley NHS Foundation Trust had been volunteering with KSLP to provide training and supervision to some newly trained mental health nurses. Unfortunately this work ground to a halt with the Ebola outbreak, and Katy switched focus to providing support for staff and patients affected by the outbreak.    It was clear KSLP were keen to resurrect the training and supervision and were committed to working with local partners to develop robust and effective mental health services.

Prior to the Ebola outbreak there was poor provision of mental health services in Sierra Leone. The majority of people requiring mental health and psychosocial support were unable to access it. There is only one Consultant Psychiatrist in the country, now retired, to serve a population of over 6 million people. There is one mental health hospital in Freetown and little mental health or psychosocial support otherwise. This situation has worsened during the Ebola epidemic. A recent study by the International Medical Corps Sierra Leone found that many people affected by Ebola are reporting psychological problems and require mental health care.

Whilst I envisioned spending my time here in Sierra Leone sweating through scrubs in full PPE in fact I am now spending most of time working outside of the Ebola holding unit supporting KSLP mental health projects. It feels like exactly what I should be doing especially as the need is so great.

At Connaught I am fortunate to work with the brilliant and enthusiastic Jennifer Duncan, one of only 20 recently trained mental health nurses posted throughout the country. Together Jennifer and I are providing psychosocial support focused on stress management and psychological first aid principles to healthcare workers at the hospital. Many of the staff have been directly affected by Ebola and lost colleagues, friends and family to the disease; together, they share experiences and promote psychological resilience.

It’s great to be working with KSLP and Connaught Hospital and to know that by developing mental health and psychosocial services we are meeting a crucial, and so far unmet, need. It is exhilarating work, in an exciting and dynamic environment, and I’m proud to be a part of it.

A Physician in Freetown

By Dr Terry Gibson, Volunteer Consultant Physician at Connaught Hospital

I joined the KSLP team in Freetown in April and Connaught Hospital has become my place of work and something of a home. My flat inside the duty house on the hospital grounds is where I sleep, and lets me see how the hospital functions after hours. Being right next door to the mortuary means the trundling mortuary trolley, followed by the sound of grieving relatives is a regular disturbance at night.

I arrived without a remit but with a shared expectation that through my long experience of acute and general internal medicine at Guy’s and St.Thomas’ I would be able to contribute to patient care, set standards for myself and act as a role model for house officers and students. That is precisely how it has evolved.

During the first week I was asked to share duties with one of the other three general physicians. On the first round together he excused himself to attend a meeting and asked me to carry on. For six weeks thereafter I continued in his place, performing daily rounds, one in three on call and a diabetic/general medicine clinic. When he returned I assumed charge of my own team so now there are four general physicians sharing the task.

Each team includes a consultant and a minimum of two house physicians who have been qualified for one or two years and shoulder responsibilities well beyond their competence. For this reason I perform regular daily rounds and a slow survey on Sundays. If on call for a long weekend I conduct rounds throughout the weekends. Dedicated training procedures are limited. I regularly perform lumbar punctures and other invasive procedures, teaching as I go. Apparently despite the large number of unconscious HIV admissions lumbar punctures are rarely performed. Thus I have set one clinical standard in motion.

A weekly clinical meeting for medicine with cases of interest or of educational value is now a regular feature of the house physicians’ timetable. My colleagues on the King’s team had already launched this idea, but the arrival of a Guy’s and St. Thomas’ physician on the wards gave the meetings a lot more impetus. It has also acted as a forum for the other consultant physicians who rarely meet but now contribute to the clinical meeting as well as engaging in a separate gathering to discuss business issues. Recently the focus has been on improving the performance of the ICU.

My outpatient session has been connected into a rheumatology/GIM clinic. The number of rheumatic referrals so far has been small. The clinic is supported by two house physicians who have learned how to aspirate joints and examine the fluids under a microscope. Whether I can emulate my time as a visiting professor in Pakistan where I started the rheumatology service in Karachi that flourished 20 years later I cannot say, we shall see.

In the meantime the support I’ve received from the King’s team and the established physicians here has been nothing but positive. All things are possible and I am optimistic about the likelihood of leaving some sort of legacy behind.

The Eye of the Storm: Ethical Challenges at the Front Line of an Ebola Outbreak

By Dr Oliver Johnson, Programme Director, King’s Sierra Leone Partnership

Last year I had the opportunity to spend time in Boston with Dr Paul Farmer, founder of Partners in Health, who generously gave me a copy of his recent book Haiti After the Earthquake, an account of the response to the devastating earthquake in Haiti in 2010.

Reading his description of their early work in the main hospital in Port-au-Prince, a sprawling colonial compound in need of a major revival, surrounded by urban slums, I was struck by the parallels with our own partnership with Connaught Hospital in Freetown – and have been kept awake at night since by an unresolved question: what would we do in similar circumstances, if disaster hit Sierra Leone?

On 25th May 2014 disaster did arrive, not in the form of an earthquake, but with the confirmation of the first ever cases of Ebola in Sierra Leone.

The news was not a complete surprise – since the outbreak started in Guinea in March, the Ministry of Health & Sanitation had been on high alert, organising regular National Emergency Ebola Taskforce meetings to coordinate preparedness and contingency planning.

The King’s team were invited into this process within hours of the first Taskforce meeting, advising Connaught on how to adapt international guidelines to develop a Hospital Preparedness Plan that detailed how to identify cases, set up isolation facilities and safely protect staff and dispose of medical waste.

These guidelines were held up as a model for other hospitals, and King’s was asked to act as technical advisors to the Ministry’s wider national Ebola Case Management committee, along with groups such as Medicines Sans Frontieres, Emergency Hospital and the World Health Organization.

We then had two months of relative calm and many began to believe that, even as Ebola had spread like wildfire across Guinea and into neighbouring Liberia, Sierra Leone might have dodged a bullet and avoided the outbreak entirely. The confirmation of cases within Sierra Leone quickly dispelled that hope, pushing us all to lift our game.

As the King’s team worked to urgently provide refresher training to nursing and medical staff, suspected cases began to emerge. Sierra Leone has been awash with rumours and misinformation for weeks about Ebola and, with a nurse having been one of the first Sierra Leonean victims, the sense of fear amongst hospital staff was palpable. We therefore found ourselves amongst the first responders to these suspected cases, alongside heroic Connaught colleagues such as Sister Cecilia (Sister-in-Charge of the Accident & Emergency Department) and Dr Eva Hanciles (Head of the Intensive Care Unit) who did not hesitate to step forward and manage the response.

Our volunteer clinical team were all re-tasked to provide support including consultant physician Dr Terry Gibson, junior doctors Dr Paul Arkell and Dr Sakib Rokadiya and nurse Karlin Bacher. They have been working late into the night to set up an expanded Isolation Unit and to provide treatment and take blood specimens from suspected patients. It has been sweaty and exhausting work, scrubbing floors with bleach whilst wearing gowns, masks and other personal protective equipment in the intense heat of Sierra Leone’s humid rainy season.

As we approach the end of the frenetic first week of the response, we are finally getting a chance to reflect on our response and the whole team has engaged in deep debate about a number of ethical challenges we have been confronted with.

The most fundamental question is whether we as an organisation should be involved in the response at all. Just like our Boston colleagues in Haiti, our work at Connaught Hospital is not aimed at providing hands-on clinical care to patients or at directly managing clinical services. Instead our focus is to support the long-term strengthening of the health system by providing training and technical advice. This represents a fundamental distinction between humanitarian and development work.

We’re therefore really not set up to provide a humanitarian response, it’s not what our team specialises in and we don’t have access to the sorts of funding or medical equipment that are needed for this. On the flip side however, we have a highly professional team of experienced clinicians, with two consultant-level physicians, two junior doctors trained in tropical medicine, two nurses, a pharmacist and a hospital manager, we have one of the largest and most senior international medical teams of any organisation in Sierra Leone. With that comes our close working relationships with local counterparts and our relative familiarity with the hospital facilities, culture and the Krio language. And we are on the ground already – whilst other international organisations take weeks to recruit a team and prepare for deployment, we are able to respond within minutes to a request for support.

Helping to respond to an outbreak of a viral haemorrhagic fever (VHF) is not a standard request for support however – it requires specialist expertise. We were lucky to have Dr Colin Brown on hand, our Infectious Diseases Advisor in the UK, who is well trained in VHF response and can draw on technical support from Public Health England and beyond. Even so, are we acting beyond our competency and putting ourselves and others at risk by taking on roles that we’re not set up to handle?

After discussing this as a team, with our local partners and with our senior colleagues back at King’s we decided, on balance, that we had a duty to respond and that we did have the capacity to do so safely and effectively – provided we coordinated closely with other specialist partners (such as the Lassa Fever Centre in Kenema and the World Health Organization).

The decision to respond opened up a question about whether or not to put our staff on the front line. Ebola is highly contagious, particularly through exposure to body fluids such as blood, saliva or urine – this means that health workers are particularly at risk. Effective use of personal protective equipment (such as gowns, masks, goggles and gloves) and effective cleaning and waste disposal can significantly reduce this risk but at the start we didn’t have all the materials we needed available and you can never eliminate the risk entirely.

Different organisations in Sierra Leone have responded to the outbreak in different ways. Some immediately evacuated international staff when cases in Guinea emerged. Others said they would do so if there were confirmed cases locally. Some put restrictions on their staff, banning them from undertaking clinical work or going into clinical areas. One organisation actually closed their entire hospital to all patients.

This is a moral dilemma in the truest sense, every option available involves moral wrong and ethical compromise making it a matter of judgement about how to weigh up competing responsibilities.

As organisations we have a duty of care to our staff, not to put them at unnecessary risk. We also have to be mindful of reputational damage; many NGOs worried that if one of their staff members died of Ebola they would open themselves up to being prosecuted or to funding being withdrawn, damaging their wider efforts to help patients.

As health professionals however, we have a duty to our patients. Withdrawing from clinical activities would not only harm patients who are suspected of Ebola, but (particularly in the case of the hospital which closed) would have enormously detrimental impacts on the care of other patients. One NGO stopped doing outreach clinics in a local urban slum – a clinic which was the only health service available to many vulnerable patients, some of whom will certainly have died as a result. And having made this decision, at what point do you decide it is safe enough to return – for how many weeks, months or years do you stay away?

Most of the decisions made by international NGOs hinged around their international staff – but what of Sierra Leonean health workers? Is it not discriminatory to withdraw internationals whilst expecting local staff to stay at their posts and face the challenge alone – especially when international staff are often better trained in how to wear protective equipment and are at a lower risk as a result.

One senior colleague at the Ministry of Health articulated this clearly – to him and his staff on the ground, it felt like the civil war all over again, as NGOs packed their white SUVs and abandoned their local colleagues at the first sign of danger, often without even telling them of their plans. In this context, was closing the entire hospital, and providing the same protection for all staff, a more ethical decision – even if a greater number of patients ultimately died as a result?

At King’s, following extensive discussions with senior colleagues in London and Freetown, we took the decision not to restrict the clinical activities of our team. We were aware however that all our staff are volunteers and that this isn’t what they originally signed up for – so we gave them the option to withdraw from clinical activities if they wanted to, asking only that they make this decision in advance so that we could communicate it to partners and put contingencies in place. All of our team have decided to continue clinical work for the moment – but has this put unfair peer pressure on individuals to agree to remain, since everyone else in the group has decided to do so?

The moral maze does not stop here though. The only way we can test for Ebola is to send a blood sample to Kenema and results can take anything from six hours to days. When a patient comes to the hospital who fits the agreed case definition we have to isolate them immediately. The case definition is broad, so most suspected cases turn out to be negative, in which case the patient is likely to have another critical illness such as malaria. But those patients cannot have any other diagnostic tests until their Ebola result comes back negative, because it’s too dangerous to expose lab staff to potentially hazardous samples.

The range of treatments we can offer them is also severely limited – in particular, the National Case Management Committee agreed that it was usually too dangerous to perform surgery on a suspected case. For example a woman in obstructed labour or a patient with a surgical emergency like appendicitis might well have symptoms that match the Ebola case definition.

Patients and their relatives are, understandably, deeply unhappy about being placed in isolation and are often terrified by being kept in an Isolation Room and treated by staff in masks. They are angry about not receiving better care and therefore  often try to escape with the assistance of relatives. Seven suspected patients escaped from Kailahun hospital last Saturday, with lab results later showing that some of those were confirmed cases. This creates a massive risk of spreading the disease.

At Connaught our hope was that by providing better conditions and clinical care in the isolation room and communicating effectively, patients would not attempt to escape. But so far this hasn’t proved enough and the police have been called in for support. Do we now lock suspected patients in the isolation room or call in the army to contain them at gunpoint? Or do we respect their right to leave and risk letting the outbreak spread out of control?

Managing this outbreak has been an enormous undertaking for all involved – from senior ministry staff holding daily meetings, to health workers leaving the wards to attend training and money has been reallocated from other programmes. But is this disproportionate? People die from malaria every day in Sierra Leone – but there have only been a total of three confirmed deaths from Ebola so far. We know that Ebola is killing people, but is the Ebola response killing people too? Should we instead be putting our efforts into preventing other bigger causes of death?

None of these questions have easy answers. We at King’s have done our best to identify the ethical dilemmas we face and to respond to them with integrity, in consultation with our own team and our local partners. I don’t doubt that we’ve got some of our decisions wrong. Part of a rigorous approach though has to include opening them up for debate, so we welcome your feedback and suggestions and hope to initiate a broader discussion on how we can provide organisations and individuals with better guidance and advice for future scenarios. As the rainy season starts, concerns about a repeat of the 2011 cholera outbreak in Sierra Leone are emerging and Connaught Hospital has been asked to start contingency planning. Should we be repeating the same role for cholera, or position ourselves differently?

In the mean time, we’ll be back on the frontline in Connaught Hospital doing what we can to support our Sierra Leonean colleagues to control this deadly outbreak.

Theory to Practice – My Elective with the King’s Sierra Leone Partnership

By King’s elective student James Barnacle

I had been interested in Global Health for several years before being lucky enough to study the intercalated degree at King’s College. It expanded and developed my interests, looking at how and why countries developed and the relationship between development and health. It was on the course that I first heard about the King’s Sierra Leone Partnership, and met Oliver Johnson, who at the time was teaching and tutoring on it.

Until my elective I had never been to sub-Saharan Africa and a year of narrowly spaced exams meant that I was reluctantly losing touch with the global health world. A medical elective with the partnership was a fantastic opportunity to consolidate what I had learnt, emerge myself in global health once again and see the theory and principles from the course put into practice. With this in mind, Anna (a colleague from Cardiff who had also studied global health) and I found ourselves outside the KSLP office on the second floor of the administration building at Connaught Hospital, not really knowing what to expect but very excited to find out.

What the KSLP office lacked in space it made up for with filter coffee, wifi and an incredibly friendly atmosphere. On our first day many of the faces were already familiar after we had joined several of the team the night before in a desperately empty national stadium to watch Malian singer Salif Keita! Oliver introduced the partnership’s work in Freetown and I was surprised at how discussions and seminars from the course were flooding back to me as I heard about KSLP’s recent achievements and future plans.

We were given several projects during the six week placement including collecting timings and demographics of those presenting through the front gates before and after the introduction of a triage system aimed at prioritising sick patients. In addition, we evaluated the nursing skills lab by performing an inventory, talking to nursing staff and students and identifying areas for improvement.

The partnership works closely with the nursing school, and more effective use of the skills lab will improve nurse training. We presented recent KSLP research at the annual Health and Biomedical Sciences (HBIOMED) national conference to leading academics in Sierra Leone. Finally, we helped analyse epidemiology data from over 350 patients to identify key presenting complaints, investigations, diagnoses and drugs. This will help direct the free emergency drugs initiative being introduced at Connaught, but in the future will be a reference for lab test requirements, disease burden and drug prescribing.

As well as liaising closely with the KSLP team, working with local staff and students was an integral part of our projects. Two nursing students, Benson and Sahid, worked closely with us collecting the inventory. In A&E, we had a strong rapport with Dr Cole and the nursing team who played a crucial part in the data collection. On ward rounds, we developed friendships with the medical students, some of whom had even visited Wales on their elective. They were enormously welcoming and always willing to answer questions about their challenges and experiences.

The autonomy we were given forced me to draw from the skills I had gained on the course, notably critical reflection in the context of health system strengthening, development and policy. Our time there gave us a window into an organisation working closely with the government to put the principles I had learned about into action. I could not imagine a more engaging and enjoyable way to put the ideas I had developed on the global health course into practice. I will stay closely linked with the partnership and hope to return to Sierra Leone in the future.