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.”

King's Team Receives Awards

Ebola in Sierra Leone Dr Oliver Johnson, Programme Director of King’s Sierra Leone Partnership, has received an OBE in the Queen’s Birthday Honours List for his services in the fight against Ebola. Will Pooley, a nurse who worked with the team for a period, has also received an MBE.

Dr Johnson has been leading a small team of clinicians and support staff in West Africa since January 2013. The team, made up in a large part by volunteers, was originally in Sierra Leone to help build and strengthen the local health system but has played a vital role in responding to Ebola since the virus first reached the country in May 2014.

They have provided a full clinical response to Ebola at Connaught Hospital in the capital Freetown.  Dr Johnson and his team worked closely with the Sierra Leone Government and local and international partners to increase the local capacity to identify and treat Ebola patients, provide essential clinical training, spread best practice quickly and, by helping set up an Ebola Command Centre in Freetown, manage the effective flow of patients across the city. Dr Johnson and colleagues also played an influential role advising the UK Government about the ongoing response.

Dr Johnson, says that: “I am humbled to receive this award, which I accept on behalf of all those I have worked with in Sierra Leone. Everything we achieved is due to the efforts of extraordinary local health workers and international volunteers, who have bravely led the fight against Ebola and did not hesitate to put their lives at risk to save others. They are the real heroes of the response, and I would like to dedicate this award to them, especially those friends and colleagues who lost their lives to the disease. We will continue to fight the virus until we have seen the last case, and to work with our local partners to rebuild and strengthen their health system in the coming years.”

The King’s Sierra Leone Partnership is an initiative of King’s Health Partners Academic Health Sciences Centre, an innovative partnership between King’s College London and three of London’s leading NHS foundation trusts – Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley.

Professor Sir Robert Lechler, Executive Director of King’s Health Partners and Vice-Principal (Health) at King’s College London says that: “This award is a reflection of the outstanding dedication and leadership shown by Dr Johnson during the past year. I am incredibly proud of what Oliver and the team have achieved in responding to such a tragic disease outbreak.”

Dr Johnson and the King’s Sierra Leone Partnership team remain in Sierra Leone and continue to respond to the outbreak, working alongside local partners to restructure and stabilise the healthcare system, helping to protect against a crisis like this ever happening again.

(cross-posted from the King’s Health Partners website)

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.

William Pooley joins the King's team in Freetown

Will1 The King’s Sierra Leone Partnership and King’s Health Partners warmly welcomes British nurse Will Pooley to their team in Freetown, Sierra Leone who are working on the frontline to halt the Ebola outbreak.

Will was previously working as a nurse treating patients in a government hospital in Kenema before being flown home from Sierra Leone in August after contracting the Ebola virus. He has now made a full recovery and flew out to Freetown today (Sunday 19 October) to join the team from King’s Sierra Leone Partnership where he will resume his nursing role. He will be working in the isolation unit at Connaught Hospital, training local staff and helping to set up new isolation units.

King’s Sierra Leone Partnership is an initiative of King’s Health Partners Academic Health Sciences Centre, a partnership between King’s College London and three of London’s leading NHS foundation trusts – Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley. The in-country operation was launched in January 2013 by Dr Oliver Johnson and aims to strengthen Sierra Leone’s health system.

The King’s team has played a vital role in responding to the Ebola outbreak since the virus first emerged in the country in May. The role of the team has rapidly extended beyond its initial management of a 16-bed isolation unit at Connaught Hospital.  They have worked closely with the Sierra Leone Government and local and international partners to increase the local capacity to identify and treat Ebola patients, provide essential clinical training, spread best practice quickly and, by helping set up an Ebola Command Centre in Freetown, manage the effective flow of patients across the city.

The team was recently awarded £1 million by the Department for International Development as part of the UK Government’s response to the outbreak. The money will allow the King’s Sierra Leone Partnership to greatly expand its activities working with local and international partners in a clinical and advisory role to help stop the spread of Ebola.

Speaking ahead of his flight to Freetown, Will Pooley said:

“I am delighted to be returning to Sierra Leone to join the King’s Health Partners team. I would like to once again thank the team at the Royal Free Hospital and the RAF who provided me with such excellent treatment and support. But the real emergency is in West Africa, and the teams out there need all the support we can give them – I am now looking forward to getting back out there and doing all I can to prevent as many unnecessary deaths as possible”.

Welcoming Will to the team, Dr Oliver Johnson, Programme Director for the King’s Sierra Leone Partnership said:

“It is fantastic that Will has chosen to join our small team here at Connaught Hospital. The situation here in Freetown is getting worse by the day and so Will’s experience and commitment will be vital as we do everything we can to stem the flow of cases. The best way of stopping Ebola spreading even further is to fight it at its source and I look forward to working with Will to do just that.”

King’s Health Partners are raising funds to help support the ongoing Ebola response in Sierra Leone. For more information please visit

Will spoke to Michael Carden of King’s Health Partners about his “unfinished business” in Sierra Leone, and you can find that interview here.

Notes to Editors

  • Will is returning to Sierra Leone to focus solely on his role as a volunteer nurse fighting Ebola. As such, neither Will nor his family will be available for media bids. We ask that you respect this desire for privacy from both parties.
  • King’s Sierra Leone Partnership is part of King’s Health Partners Academic Health Sciences Centre (AHSC), a pioneering collaboration between King’s College London, and Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley NHS Foundation Trusts.
  • King’s Health Partners is one of six AHSCs in England and brings together an unrivalled range and depth of clinical and research expertise, spanning both physical and mental health. Our combinedstrengths will drive improvements in care for patients, allowing them to benefit from breakthroughs in medical science and receive leading edge treatment at the earliest possible opportunity. For more information, visit
  • To find out more about King’s Sierra Leone Partnership visit
  • For all other media enquiries about the work of King’s Health Partners in Sierra Leone, please email Michael Carden, Head of Communications at / 07825 546177 or email

Statement: Gambia Bird flights suspended

King’s Sierra Leone Partnership Programme Director, Dr. Oliver Johnson, had this to say on the decision by the UK Civil Aviation Authority:

“The decision of the UK Government to withdraw permission for Gambia Bird to operate direct services to Sierra Leone is very disappointing, particularly as it is inconsistent with the current travel advice from both the World Health Organisation and the UK Foreign Office. King’s Health Partners and the other organisations fighting Ebola in Sierra Leone depend on flights from overseas to provide us with vital resources, including both personnel and equipment. The reopening of direct Gambia Bird flights between London and Freetown would provide a much needed route for urgent support. We had an urgent shipment of critical supplies and two volunteers due to arrive on Friday with Gambia Bird that will now be delayed, a tangible example of how this decision will impede the response in West Africa and put UK nationals supporting the response on the ground at greater risk. Whilst it is completely understandable that the UK government is doing everything it can to ensure the country is ready for any potential cases of Ebola, preventing flights from West Africa will not help with this. Regular, direct flights from the affected countries are easier to monitor for potential cases than indirect flights routing through many different airports in Europe. The best way of stopping Ebola arriving in the UK is to tackle it at its source and I would urge the Government to reconsider its decision.”

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.

Spotlight on surgery


Improving surgery in low resource settings was the focus of local and global attention at the Lancet Commission Meeting on Global Surgery held in Freetown from 19th-21st June 2014.

The three-day conference hosted by King’s College London and Lund University drew commissioners and advisors from 28 countries including several representatives from King’s Health Partners.

While discussions addressed the need for surgery through a health systems strengthening framework globally, the Freetown setting provided much of the local context for discussion and generated significant momentum for the country’s need for strengthened surgical care.
The meeting gained the support of Sierra Leone’s President Ernest Bai Koroma who met with 10 of the commissioners to pledge his support to advocate for the work of the Lancet Commission at the United Nations and amongst other heads of state.

Mr Andy Leather, Co-chair of the meeting and Director of The King’s Centre for Global Health, highlighted the importance of the Commission in promoting the work of King’s Sierra Leone Partnership. “This meeting has focused attention on the need for better surgical care in low resource countries. As partners working with Sierra Leonean surgeons, we are delighted that the country’s need for post-graduate surgical training could be brought to the President’s attention through this forum. We are grateful for his commitment to address the needs of his people by training surgeons for Sierra Leone within Sierra Leone“. said Andy.

Doctor T.B Kamara, Chief of Surgery at Connaught Hospital in Freetown and a key partner to the King’s Sierra Leone Partnership was also one of the commissioners at the meeting. He is also positive about the importance of holding the Commission in Freetown and the significance of what it has achieved for surgery in the country.

“The Lancet Commission meeting accomplished what is beyond our expectations. At the start of this process, I alone was the voice of the Lancet Commission in Sierra Leone but it now has the enthusiastic engagement of a much wider community, from surgeons to policymakers. We gained the attention of the President who is committed to advocating for global surgery and he made a commitment to postgraduate training in surgery in Sierra Leone. This has given momentum to passing the parliamentary bill we need to establish a post graduate surgery training programme“. said Dr Kamara.

The Commission will culminate in the publication of a 20,000 word report that will provide a reference for governments, policy-makers, international bodies and other stakeholders to engage in concrete action. The key findings and priority actions will facilitate the development, implementation and evaluation of surgical policy to promote the delivery of surgical services worldwide.

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 h
owever, 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.