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Wednesday, 4 June 2014

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.

     Myself with Connaught staff Dr Martin Salia and Sister Cecilia (Sister-in-charge of A & E)  preparing the isolation ward. 

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.

    King's volunteer nurse Karlin Bacher works with Nurse Susan to review the Ebola guidelines

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).

    Setting up the isolation ward at Connaught Hospital

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?

King's volunteer Dr Sakib Rokadiya dressed in protective clothing before assessing a suspected Ebola patient  
(who later tested negative to Ebola).

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.

7 comments:

  1. A brilliant article containing, in your words, many difficult questions with no easy answers. Sounds like everyone at Connaught is doing a tremendous job. Hang in there! Sneha

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  2. Oh I pity health workers both local and international in trying to contain this Ebola conundrum...indeed one can see the ethical and moral dilemmas surfacing from every angle...but the crux of the matter is that this should serve as a wake up call informing the country as a whole of the potential vulnerability and frailties of our health system...which I believe need some much needed overhaul...but thanks guys for your brilliant and gallant efforts in the face of death...Stay safe and all the best

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  3. I am a medical officer of the Ministry of Health and Sanitation who is currently doing a double masters in international public health and health management...and I could still recall the haphazard way in which the last Cholera outbreak was tackled in my work station at Portloko Government Hospital and the district as a whole...there was so much that we could have done better.Health and emergency preparedness during infectious disease outbreaks and natural disasters as well as a robust disease surveillance system are things we should think seriously about

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  4. Please note I don't have a medical, but rather a communications background.

    I understand medical staff is at a real risk when treating patients suffering from ebola. I admire the honesty of the article above in highlighting the choices this risk entails.
    That said. It appears that communication/information issues (partly with historical, social and cultural roots) make this outbreak worse than it could be. In that context, here's my question: is it correct to call ebola virus "highly contagious"?

    Looking at the transfer to humans, I understand it only takes a minimal exposure to the pathogen to become infected: small in duration and quantity. But wouldn't this rather be called "highly infectious"?

    Contagious seems to mean communicable, here typically used to denote the virus can transfer from one human to another. Limitations on how communicable ebola virus is, seem to be
    -it is probably not respiratory/aerosol transmitted, one would need exposure to cited body fluids. Doesn't this mean ebola would compare less communicable to e.g. influenza, measles, SARS?
    -a person only becomes contagious after displaying symptoms. Doesn't this also makes a difference with a virus that can spread before any symptoms are noted?
    -people get very sick and have a high chance to die. Doesn't this also limit the chances of transfer?

    Again, yes, health workers are at a real risk of contamination with a virus that doesn't have a cure and that is often lethal after contamination. Thus laboratory research on Ebola is conducted in the highest safety environment.
    But calling Ebola "highly contagious" seems to suggest that catching ebola is as easy as getting the flue.
    As I understand it, in the plainest possible language: it is not thàt easy to get Ebola virus, but you are very likely to lose your life when you do. If Ebola really was "highly contagious", wouldn't we have outbreaks on a very different scale? If I am correct, the human cases of Ebola in Europe and Russia so far were either from lab accidents involving punctures or cuts, or from a necropsy.

    Why raise this? Suggesting a virus can jump very easily from person to person, could divert attention from the specific means of transmission. It can fuel extra fear and suspicion, possibly making it more difficult to get vital information across or to inspire trust in medical staff.

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  5. Hi Peter,

    Thanks for your comments - you're right that the risks of the Ebola spreading are more complicated than it may initially seem. Ebola isn't aerosolised (unlike swine flu etc) so you don't have the same threat of it spreading in public places (like public transport or mass gatherings etc). If you have direct contact with body fluids from a person with Ebola though (e.g vomit, diarrhoea, semen) there's a relatively high likelihood that you'll become infected yourself - especially if you don't follow safe practices like hand washing, or wearing protective clothing (like aprons or gloves).

    As you say, what makes Ebola so dangerous is more the high mortality rate (probably more than 50% in this outbreak) and the lack of a specific cure (although supportive treatments like fluids, and preventive treatments like antibiotics, significantly increase your change of surviving).

    That doesn't mean that there is no risk of Ebola spreading within and beyond West Africa though - there is the small but tangible risk of sick patients travelling elsewhere and exposing others to the disease. In Europe and the US though, we have strong infection control practices amongst the public and health workers, and excellent disease surveillance and and outbreak response systems, so it's very unlikely that Ebola would spread much further.

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  6. It’s admirable what you are achieving and what you are doing in partnership with Kings in Freetown. It was very eye opening to read your blog and raised many issues I didn’t even think about. I am confident that as a team you have done your level best to respond to all the dilemmas you have faced with dignity and care. As a nurse and someone who has spent time in Freetown I can imagine the challenge it has been for you all. Thoughts are with you all! Keep up the amazing work.
    Hannah Mulvihill

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