There are not many places in the world where you scrub your hands with alcohol getting off the plane before you enter the airport terminal; have a temperature gun held to your head every time you enter a hospital, and again every time you leave; where makeshift hand-washing facilities – large tubs with a tap and bucket – greet you seemingly at every corner. There are not many places in the world like Freetown, Sierra Leone in 2016. Ebola has gone, but its legacy lives on.
Large four-wheel drive vehicles continue to cruise the streets, logos slightly tatty but still legible: World Hope International, Save the Children, World Food Programme. The 2014 outbreak was declared over in January 2016, with no new cases for 42 days. However, we now know some people carry the virus for longer than previously thought, so there is always the chance they will pass it to somebody new: every few days a patient with a suspect fever needs investigating.
At the UK aid screening tent in Military Hospital 34 the Sierra Leonean nursing staff are relaxed. The last positive patient was months ago – and there is almost a party atmosphere as they joke and tease each other, a spirit that was captured in Bye Bye Ebola, a video that went viral after the country was declared free of Ebola.
In the adjacent tent is a survivors’ clinic – 4,051 patients have survived Ebola virus disease and been discharged, declares the Ministry of Health and Sanitation’s website, but that does not mean their difficulties have ended. Work led by my colleagues at the University of Liverpool, and others, has shown that Ebola survivors can be left with a whole series of problems, from joint aches and depression to blindness and deafness. I have come to help assess their neurological sequelae – the problems left over after their previous infection – working alongside the country’s only neurologist, Durodamil Lisk.
I meet Amadu who is running a survivor clinic run by one of the non-governmental organisations: “First I examine the Ebola survivor certificate to check it is not fake,” he declares. “Then I ask for additional photo identification to be sure they are who they say they are.”
It seems bizarre that anyone would falsely claim to be an Ebola survivor, especially given the stigma, but Amadu explains: “We provide all sorts of services that people want – medical checks, support, counselling. But it is only for the Ebola survivors.”
What if you didn’t have Ebola, but all your family died from it and you need help?, I ask. Does that not make you a survivor? He starts to shake his head. “We bend the rules where we can,” interrupts the clinic supervisor, a Brazilian woman with years of experience, “but where do you draw the line?”
Focused on just this one group of patients, the clinic has a calm and gentle feel. On the other side of town, at Connaught, the national referral and university hospital for adults, it is a different story. Built by the British in 1817, Connaught is a hustling bustling general hospital with patients and their families in every nook and cranny. This is the Africa I am used to. At the back, tucked away behind the medical ward I find a small office cramped with British medical volunteers from the King’s Sierra Leone Partnership, established in 2011 by King’s Health Partners, an academic health sciences centre in London.
“King’s were here before the Ebola epidemic; when many other NGOs left we stayed to help run Ebola isolation and treatment services across Freetown, and now we are part of the rebuilding process”, explains Paddy Howlett, a junior doctor from London who has taken two years out of his training in Britain. “The country has been devastated by the Ebola outbreak, but of course the roots of the epidemic are in poor health infrastructure, inadequate resources and a lack of trained staff; none of these has improved enough since the time of the civil war.” His voice trails off thoughtfully. “Even before Ebola, being born in Sierra Leone your life expectancy was 45.”
Howlett was in Sierra Leone as a medical student with Medicine Sans Frontiers almost a decade ago. Like many similar organisations their remit is emergency relief, not long-term development, and so they left soon after the war ended in 2002.
“Most people agree that the Ebola situation got so bad because of the poor medical infrastructure after the war,” he says. “You can’t help wondering how different Ebola would have been if all those emergency organisations had stayed to help build up the national health system.” Once again, now that the crisis is over, many are leaving and the funding has dried except for a few specific areas. “It is the same everywhere,” I tell him. “But imagine if these short-term relief organisations agreed to always reserve a small amount of funding for longer-term support – say 10% for ten years”. Yes, wouldn’t that be something!
I meet other doctors and nurses in the team. They are young and, although they all look thin and exhausted, their enthusiasm and passion beams from their faces. I have worked in some tough environments over the years, but Sierra Leone must be one of the most challenging. Even in the most deprived countries there is usually some kind of basic health provision for the poorest people; but here no money means no healthcare. “Even for those with money there are only a handful of investigations available,” explains Fennella Benyon, an infectious diseases clinician, “and only a few drugs”.
On the ward round we therefore resort to our basic clinical skills, taking a really thorough history and examining the patients very carefully. This is a million miles from the Walton Centre in Liverpool, where I usually work. At the Walton we have four MRI scanners. There is not a single one in the whole of Sierra Leone. Even CT scans are hard to get – and for each patient we weigh up carefully whether the additional cost is worth it. Many of the hospital staff are unpaid and the little equipment that is donated does not last because of power surges. It feels desperate, but the King’s team remain cheery and focus on what they can do to help. Ruth Tighe, a critical care doctor from Brighton, proudly shows off the “oxygen factory” she has set up with the engineers. “It’s not what I was trained to do, but it’s making a difference.” Piping oxygen to the intensive care unit, full of critically ill patients struggling to breath, has brought the mortality rate down by 20%.
In the Emergency Department we meet Sister Cecilia. She has bright blue scrubs on and hair pulled back in a tight bun. “This is where we screened the Ebola patients during the epidemic. Hundreds of patients passed through here every week. Afterwards there was lots of money so we used it to refit the whole unit. Look, now we even have monitors,” she laughs. We bump into Richard Lowsby, an emergency medic from Merseyside, who is looking for beds. “This is not like at home, where looking for beds means asking the nurses for empty beds that new patients can go into,” he explains. “The surgical side of the emergency department is opening next week, so I am literally searching the hospital for any old unused beds to go in it.” It is a hands-on approach to help the hospital make sustainable and steady improvements.
We wish him luck as he heads off down the corridor. Around the hospital “obituary” posters of doctors who died in 2014 are pasted on the walls. They are faded and peeling now, but I recognise some of the names from the Ebola Doctors Memorial outside the health ministry.
The Connaught internal medicine department, led by the charismatic Gibrilla Deen, has set up extra neurology and psychiatric services for Ebola survivors, to complement the clinics they offer other patients. Anna Walder, a psychiatrist from London, talks with us about the depression and anxiety she has seen in the survivors. “But the amazing thing is how well people are coping,” she exclaims jumping up. “Just compare it with what you might expect for a disaster like this in the UK.” Howlett agrees: “Sierra Leoneans have an incredible resilience and positive outlook on life. It’s admirable and maybe a consequence of all they have been through.”
I join Lisk, the neurologist, who is assessing survivors for long-term damage. He trained in the UK and we find we have many neurology friends in common. “The problem now is our doctors go overseas for training, but then they don’t come back,” he sighs. “And who can blame them?” A notice on his desk reads: “Imagine this hospital with all the medical and surgical specialties; an intensive care with ventilation and haemodialysis. This is not Connaught Hospital in five years’ time. This was the hospital 20 years ago.” “The war set us so far back,” he explains.
We start the clinic. The survivors are greeted by the nurses like old friends, with hugs and laughter. Lisk looks midly uncomfortable as he dons his gown and gloves to examine them. “I don’t feel good about it,” he says to me apologetically, “but there is still so much we are learning about this virus.” Given what we are now discovering about long-term carriage of the virus I have some sympathy with his predicament.
Like many Sierra Leonean women, our first patient Patricia looks magnificent in her glittering yellow clothes. But she is downcast and avoids eye contact as I introduce myself. However, once I ask her about where she is from, and we talk about this beautiful country, she brightens up. She caught Ebola from her husband, she explains, a policeman who died of the disease. None of her three children were affected but they are now living in an orphanage. With no job, and shunned by family and friends she has no means of supporting them. “They are better off there,” she says. Although she tries to sound positive, her smile cannot hide the sadness in her eyes. Our next patient, Fatu, stayed behind on the Ebola treatment unit after she had recovered to help look after children affected by the disease. Her ongoing headaches and memory problems are slowly improving.
After my brief visit there is much to think about. I continue to be amazed by the dignity of the survivors, and the heroic efforts of some of the local and expatriate staff, as well as the patients. I don’t think I have ever washed my hands so many times in my life, or had my temperature taken so often. The final check is just before I board the plane home – 36.3°C is scrawled onto my boarding pass and I am good to go.
Some of the names in this article have been changed.