Namaste Nepal

It is almost 3 months to the day since the 7.8 magnitude earthquake rocked Nepal killing more than 9000 people, injuring 22000 and leaving 2.8 million displaced. There have been 350 aftershocks since then, 16 within the first 3 hours and the latest one at 10.14pm last night. The room shook more violently than in any of the aftershocks I've experienced and there was a sound like a deep rumble. Or maybe it was completely silent and the noise came from inside my head, I can't remember. The roads were empty of traffic and quiet except for the sudden barking of stray dogs and within 7 seconds it was over. Some of us had grabbed our passports and emergency kit bags, some had gone outside looking for the relative safety of open space. For me it was a reminder that I am in Nepal and less than three months ago an earthquake with 63000 times more energy than the one I felt last night wiped out whole villages, entire families.

Seven weeks ago I arrived in Kathmandu to be part of Save the Children's Emergency Response Team. Already 5 weeks after the first earthquake the Health team was well established and had been running mobile health clinics in remote districts where health facilities had been destroyed. The Water and Sanitation team had installed toilets and clean water systems and the Education team had set up Temporary Learning Centres (TLC's) to act as classrooms in damaged schools. The Food and Secure Livelihoods team were helping to distribute rice, grains and oil and the Child Safeguarding Team were working to reduce the numbers of children trafficked, a sad reality in times of extreme poverty and desperation.  So I joined a proactive, passionate, multinational team to focus on rebuilding the health systems and facilities in 33 village district councils of Nepal.

Kathmandu views

In parts of Kathmandu it is hard to see signs of the earthquake. The infrastructure in the capital city was undoubtedly better than that in the remote villages. Road works and piles of bricks are tell-tale signs of earlier damage and the rebuilding efforts now in progress, as are the tent camps that still dot the city. But it is outside of Kathmandu Valley where the real extent of the destruction can be seen. Some of the remote areas bordering China remain completely cut off from land access and now that the monsoon season has started it is only getting harder to travel by roads that are blocked by landslides. The race is on to get the corrugated iron sheets for shelter, medical supplies for health posts and materials for temporary structures to where they need to be before the harsh winter sets in.

Yet Nepal remains a stunningly beautiful country. The compassionate, karmic religions of Hinduism and Buddhism make up 90% of the nation and interweave in a religious harmony that create a people who are incredibly kind, welcoming and inherently peaceful. The most important Hindu temple dedicated to god Shiva, Pashupatinath, is 5 minutes from our office and attracts many elderly followers of Hinduism each year. They arrive to find shelter for the last weeks of their lives, to meet death, be cremated on the banks of the river and travel their last journey with the waters of the sacred river Bagmati, which later meets the holy river Ganges. It is believed that those who die in Pashupatinath Temple are reborn as a human, regardless of any misconduct that could worsen their karma. On my birthday we walked to the office through the grounds of the temple and saw the preparation of a body for one of the many funeral pyres. Whilst obviously a sad experience, it was also moving as we witnessed the cycle of birth and death that is intrinsic of Nepal and its people.

Funeral pyres on the banks of the Bagmati river

Sādhus at Pashupatinath temple

A long road

The biggest tragedy of all is that surviving Ebola is only the start of a long, troubled journey. An indiscriminate disease that respects no social, educational or economic boundaries and is spread through the most natural of human tendencies - touch - can wipe out entire families and does so without compassion. Those you love most, those you hold and kiss, those you care for when they are dying - they are the ones who make you sick, as you then cause your own husband, wife, children and neighbours to run the Ebola gauntlet. To endure weeks in an Ebola Treatment Centre (ETC) cared for by people with faces you can't see; watching people die around you. To survive the humiliating, incessant diarrhoea, the weeks of rehydration therapy, the days of waiting and waiting for that negative Ebola test, to be finally discharged and find out that your children didn't make it; that your parents are both dead; that you are the sole responsible survivor left to care for your brothers and sisters - that is incomprehensible.

Then to return to your home in a village where, at best, many people will not come near you out of fear of the disease, to those who stop doing business with you so you can't support yourself or your remaining family. To the worst case where survivors are so stigmatised and victimised that they are no longer physically safe - people you should trust break into your home and leave you in such fear that you can't sleep, eat, live in peace. Basic human rights that above all, you should be entitled to.

As the number of Ebola cases continues to fall in Sierra Leone, many ETC's have closed or been placed on standby meaning unless there is a surge in patient numbers, the centres will remain shut to new cases. This has allowed time and attention to be spent on running Survivor Clinics where patients are invited to return for medical, psychosocial and nutritional follow-up. Brothers and sisters attend together, fathers and children, husbands and wives. All some of the lucky 50-60% of people who survive the disease. But as I read through their reports the reality hits. Fatmata lost her six month old daughter and her husband. Ibrahim lost his wife and now has 5 children to take care of alone. Kadiatu and Cecilia lost both their parents, all their siblings and 6 other family members. No-one has an income. No-one has enough food. Many have chronic joint pain, eye problems, hearing loss, headaches, alopecia, stomach ulcers. They all feel very, very sad. But they come back. They come back to the same place where weeks or months earlier they left as an Ebola survivor to much joy and celebration.  Celebration that they had survived a vicious disease and could return to their homes with the Certificate that would state they were clear of Ebola and not a threat to their communities. 

Through it all, the essence of the Sierra Leonean people shines through. There is a glimmer of hope in the eyes that look back at me. All is not lost. And when I ask in Krio 'Aw Di bodi?' (how are you?), I receive the reply 'Thanks to God' and I feel incredibly humbled and grateful to be in the presence of people who despite everything they have lost and all the troubles they face ahead, are still thankful to be alive.

To make a donation to support orphans of Ebola please consider:

http://www.stgeorgefoundation.org.uk/

A day in the life

I wake up before dawn to the calls of the fishermen on the shore 50 metres away as they arrive home with their catch. Men from the nearby village come and help pull in the nets whilst the woman sit back with their colourful buckets, watching patiently until the fish are flapping on the sand. At that moment they descend in a wild mêlée to get their share of the best fish to sell or feed their families. I can hear the buzz and excitement even over the air-conditioning unit in my room - on this deployment to Sierra Leone with Save the Children we have been very fortunate to stay in a standard of accommodation above that normally expected on a humanitarian mission. For the last 4 months I have lived in a beautiful location on the beach, in a hotel with a swimming pool, where I don't have to cook, clean or do any of my own washing. Not what I expected when I applied to work in one of the poorest countries in the world and certainly in stark contrast to the village located  outside the walls.

The journey to work at the Ebola Treatment Centre (ETC) takes 30 minutes in one of the minibuses that shuttle us to and fro at the start and end of each day. For the first time since I arrived in January this morning it rained. It rained the type of rain you only experience in the Tropics; a sudden, dark, angry downpour of such fury that even the goats took shelter under the plastic sack awnings of the makeshift houses we drove past. Just as suddenly it's over and while the dust is still settling, the humidity begins to soar.

On arrival at the ETC, temperatures are checked and hands are washed in 0.05% chlorine. By the end of the day this routine will have been repeated upwards of 30 times. A temperature above 37.5°C results in being denied entry into the ETC and a sit down in the shade; a second high reading and the doctor is called. Putting on scrubs in the changing room someone will invariably make the standard appeal: "Has anyone got a spare pair of socks?". Nobody wants to go barefoot in rubber boots the whole day.

After opening the pharmacy, greeting the staff, recording fridge temperatures, emptying bins and disinfecting the benches, it's time for the 8am clinical handover where the night team presents how the patients have fared since the previous evening. Requests for further IV fluid for patient A, ceftriaxone for patient B and frequent nappy changing for patient C are noted. I record any new medications that have been prescribed overnight or any drugs not given on the morning round and make sure they are available quickly for the next team preparing to go into the red zone. Having a pharmacist present at the handover gives me the opportunity to intervene on formulary substitutions, advise on correct dosing, draw attention to interactions and suggest treatment options, for example. It is also an opportunity for the pharmacist to highlight their role within the multi-disciplinary team - the ETC is staffed by Sierra Leonean clinicians, NHS doctors and nurses, and the Cuban Medical Brigade - not all familiar with the benefits a pharmacist can bring to patient care.

Morning handover

The pharmacy department is made up of pharmacists and pharmacy technicians from the Sierra Leonean Ministry of Health, Save the Children International and the UK Ministry of Defence. This multi-cultural, multi-sector working atmosphere brings together an interesting mix of experience, protocols and pharmacy practice. The disciplined and comprehensive approach of the MOD pharmacy team combined with the enthusiasm of  the national staff makes for a fantastic, fun working environment.

Phil, Teresa, John, Harold and Al Hassan - some of the pharmacy team

Other morning duties include packing down medicines like paracetamol, multivitamins, and zinc into individual patient doses. These and other common medications are stored in small quantities on the Nurses Station so that they are available 24 hours a day if required. When a team goes into the red zone they take with them any medication needed at that time in the quantities prescribed and administer it to the patients themselves. Drugs required once the team is already inside can be requested via the radios located in the red zone and sent in through hatches in the fence. Pharmacy is responsible for making sure the medicines are topped up twice a day and that the supply of IV fluids is maintained.

Michael, Mary, Sorie, Samuel and Tariq in the pharmacy

Having been trained in Personal Protective Equipment (PPE), I prepare to go into the red zone preferably before the hottest part of the day. With a buddy, usually one of the doctors or nurses, we follow the strict protocol and spend 20 minutes 'donning' our gear including suit, mask, hood, apron, two pairs of gloves, and finally goggles. After checking each other for breaches, our names are written on our hoods and the current time written on our sleeves, and we are cleared to enter. My jobs in the red zone include checking that no medications are being stored on the wards, that syringes of IV drugs have not been left lying around and that there is no glass - bottles or ampoules - inside. Glass equals the potential for cuts of skin and tears of PPE - one of the worst possible incidents in the red zone. All parenteral drugs are reconstituted and drawn up in the green zone to keep the risks to a minimum.

The 'donning' room

Being in the red zone is a physically challenging experience and a very humbling one. Meeting the patients who until then have only been a name on a whiteboard, talking to them, trying to make the children smile - these are some of the memories I will take away with me. Within 30-40 minutes the heat becomes too much. I can no longer see clearly through my misted goggles and the sweat that drips down your face collects in the mask in such quantities that some people have to swallow it just to be able to breathe. The decontamination process is the most important step of all and takes another 20 minutes, so it is important to consider that when judging how long you can tolerate in PPE.  The 'deconners' are amazing men and women. When you no longer have the mental acuity to undress safely through heat exhaustion, step by step instructions are called to you by the chlorine-wielding hygienists, many of whom were farmers, drivers or teachers before the Ebola outbreak.

Hygienists

De-conning

After a lunch of African stew, the afternoon involves stock checks, stock reporting and preparing to place and receive international orders. The most important role of the pharmacist in the humanitarian context is ensuring that the supply chain is intact, reliable and efficient. Managing the levels of medication, IV fluids and medical sundries fall under the remit of the pharmacist. Accurate stock levels must be kept to pre-empt and avoid stock-outs.

Stock checks

Meetings with the health teams and the logistic teams fill the rest of the day along with teaching the national pharmacists aspects of clinical pharmacy, auditing skills and how to use the new pharmacy dispensing programme. On a good day there may be a discharge ceremony to attend for a patient finally clear of Ebola. Having the best air-conditioning at the ETC not to mention a kettle and a cafetiere, the pharmacy is also a popular place for colleagues to pop in for a well-earned coffee and a cool down. I think I can officially add barista to my list of skills gained on this deployment!  

A discharge ceremony

For ten hours a day, six days a week my life is at the ETC. Evenings are spent chatting with new friends over dinner or a drink, using the projector to organise a movie night, or having a beach bonfire. Sometimes it really is necessary to forget about Ebola for awhile.

Maseray's Story*

*A fictitious account of a journey that over 400 patients have taken through the ETC 

Two months ago I went to the funeral of a man in our village who had died of Ebola. Back then there were more cases of families hiding away their loved ones who were sick. They were scared that if they admitted the illness they would be taken away, sometimes to an unknown place, and that they would never be seen again. So people were dying at home. In our culture we help cleanse the body at funerals and touch and share tears with the bereaved to show sympathy and support. A week later I started to develop aches and pains, and two days later, fever and diarrhoea. I called 117 and an ambulance arrived and took me to the Save the Children Ebola Treatment Centre (ETC), near to my home.

When I arrived at the ETC I had to wait in the locked ambulance whilst the doctors and nurses dressed in their Personal Protective Equipment (PPE). Then they took me into the Red Zone whilst a team of hygienists decontaminated the ambulance inside and out with high strength chorine. I was in a 10 bed ward and had a blood test for Ebola and a cannula inserted. I was tired and very afraid - later I learnt I was then at Stage 2 of the disease.

Other patients were coming to the ETC on foot. At the gates, nurses were asking them questions to identify the chance of Ebola. Some people were sent away again but if they had symptoms of the disease they were admitted to the suspect ward where they would stay until they were either tested as positive and moved to a confirmed ward or negative. From that point there are only two ways out: through the 'happy shower' or through the morgue. 35% of us made it through the happy shower.

One of the new Suspect wards

There is no cure for Ebola. The treatment is rehydration with intravenous fluids to replace all that we lose through vomiting and diarrhoea. I was given antibiotics, pain-killers, vitamins and medicines for nausea, agitation and reflux, all common symptoms of the disease. All of us had liver and kidney damage caused by the virus. The boy in the bed next to me started to bleed from his gums one night. They gave him special injections but two days later he died. He was at Stage 3.

There were several children admitted to the ward with me. Their mothers couldn't come with them so it was down to the female patients to care for them, feed them, play with them and sleep with them. The doctors and nurses came to the ward in teams every couple of hours throughout the day and night to check on us, give fluids, medicines, take blood, and help clean those of us who were too sick to do it ourselves. They brought toys and balloons for the children but many were too sick or scared of these people in strange uniforms and they often cried and hid away. We also saw pharmacists, the Quality Assurance team and lots of WASH staff who cleaned and chlorinated the wards and disposed of the waste and sharps bins to make it a safer place. They also took away the bodies of those who died. We could only see the eyes of the people who came to look after us and their names which were written on their heads but we started to get to know them. My friend Haja even wanted to marry one of the doctors which was funny as she had no idea what he looked like under his uniform. There were lots of different nationalities - some from the UK, some from Cuba, Sierra Leoneans and others from Canada, the US and Australia.

There was a lady on our ward who had been there 25 days. She had been cured of Ebola but then she had a stroke. She couldn't walk or take care of herself. The doctors and nurses did their best to help her exercise and walk again but there are no medicines here for stroke and no way to diagnose it for certain. Eventually she did go home after her family had been taught how to help her move around safely and she was given a wheelchair, commode, a new bed and mattress and driven the 200 miles back to her village by a Save the Children ambulance.

The days are very long for us. There is nowhere to go. Through the wire fence we can see the staff outside in the green zone. Food is passed in to us through a hatch. It is very hot and there is nothing to do except talk to the other patients if they are well enough. There are buckets at the end of our beds for us to use if we can't make it to the toilet in time. Once, my auntie came to visit me from the village. She was taken to the other side of the fence and with a 2 metre gap between us we were allowed to talk. She hadn't seen my family for a week as they were quarantined in their locked house after I had been taken away.

My personal journey through the ETC ended after 12 days. I received my second negative Ebola test 3 days after my last symptoms and was prepared for discharge. My clothes and shoes were taken away to be burnt and my phone, money and books were destroyed. Nothing taken into the red zone can ever come out again. I went to the happy shower where I was scrubbed head to toe with 0.05% chlorine and again with soap and fresh water. Walking through the happy shower to the green zone on the other side, there were nurses waiting there who gave me new clothes and shoes, bedding, towels, a new phone, money, a supply of food and a survivor's certificate which I will show to the people in my village so they aren't scared when I return home.

I am one of the lucky ones.

A Discharge Ceremony

Early Days

As humanitarians would say, I 'deployed' three weeks ago with a suitcase full of alcohol gel from dad, a 6-pack of Handy Andies from mum and a guitar, a last minute purchase from Amazon. In hindsight, I'm not sure that teaching myself how to play the guitar in the middle of an epidemic was the best idea I've had, but it certainly wasn't the worst.

Connecting in Casablanca, my initial thoughts were that the plane to Sierra Leone would be empty as who in their right mind would be heading that way? I was wrong - the airport was full of young, white, European NGO workers all congregating in eager huddles talking about life post-Ebola.

So here I am in Africa again. West Africa this time, with a humanitarian NGO not a development one and during the 18th known outbreak of the viral haemorrhagic disease, Ebola. In truth I see very little of the real Sierra Leone. For an hour each day on the drive to and from the Ebola Treatment Centre (ETC) I see the country that is my home for the next 6 months through the windows of an air-conditioned minibus. It looks very similar to Tanzania in terms of poverty and social structure judged only by the simply constructed houses, the scantily clad children and the goats and dogs making unpredictable forays into the path of oncoming traffic. But actually it is much lower down the UN Development Index with a life expectancy of only 45 years and a GDP per capita of $1586. Sierra Leone sits at position 183 out of 187 countries on the Human Development Index which takes into account a long and healthy life, knowledge and a decent standard of living.

The remaining 23 hours a day I am either at the ETC officially working or at the hotel unofficially working. By that I mean many of the most productive conversations about how to improve the way things work at the ETC are done on the journeys to and from it or over the table at breakfast or dinner. Most people here are on secondment from the NHS for 5-6 weeks so the passion for talking about Ebola doesn't wane. Ten minutes ne'er pass without a mention of work, one of the patients, national case numbers or Ebola in some context or other.

The ETC

We are incredibly lucky to stay in lovely hotels due to a lack of other local accommodation that could house so many staff. The Place, The Sands and The Palms offer varying levels of comfort and privacy with upgrade from one hotel to another forming the main bone of contention between us 'deployed'. Politics are rife and relations are tested if someone moves further up the beach before you do. Heaven forbid should somebody get a room at The Place without first staying at The Palms or The Sands. The Place has become the epicentre of our lives outside the ETC. With 24 hour electricity, air-con and Wi-Fi, The Place is also where all meals are served and where minibuses to and from the ETC depart. I think this goes a long way to explain why people would exchange their first born child for a room here. Needless to say as an old hand with three weeks experience, I am comfortably interned in my shiny room at The Place where the bathroom is bigger than my bedroom in London and the hot water rain shower and mini-fridge make it hard to believe that outside the hotel walls is one of the poorest countries in the world. 

Our bosses are protective of us and we aren't encouraged to leave the hotel grounds. Several people have made a break for it and gone for runs along the beach but it's only a few kilometres before an estuary blocks the way and you have to turn back. One person who shall remain unnamed escaped all the way to Freetown for a night but this required much planning and friends in high places. As the daily routine remains the same, the weekdays and weekends merge into one and life in Sierra Leone becomes much like that of Groundhog Day or The Truman Show. Only usually without the cameras unless the BBC pops by again...

Sierra Leone: A bit of background

There is no denying Sierra Leone has had a tough past. Having not long established peace following a ten year civil war followed by years of UN peace-keeping and overseeing of elections, in July 2014 a state of emergency was declared in response to the latest Ebola outbreak in West Africa. For the past 8 months schools, cinemas, nightclubs and football grounds have been closed. Gatherings of more than 5 people have been banned (except for church) and a curfew has seen shops have restricted opening times and no-one permitted on the streets after 10pm. Hand shakes and hugs are forbidden, temperatures are checked and buckets of chlorine are found everywhere for hand sanitisation. A journey from Freetown to Kailahun where the first cases of Ebola were reported has increased from 5 to 7 hours due to the 14 mandatory temperature checkpoints along the way.

The healthcare system has buckled under the pressure. Eleven Sierra Leonian doctors have died of Ebola since the start of the outbreak. Since November 2014 the figures on nurse fatalities are no longer being recorded due to the high number. Hospitals have closed due to lack of staff and many of the ones that remain open have cancelled operations and are not accepting suspected Ebola patients. Holding centres and ETC's (Ebola treatment centres) have opened to support the healthcare system by providing 1,207 beds in 23 ETC's around the country. Save the Children's ETC in Kerrytown where I am based is one of them.

The Western area of Sierra Leone which includes the capital Freetown and Kerrytown has become the hotspot for new Ebola cases. Last week, 31 houses in Freetown were under quarantine by armed guards with family members of confirmed patients no longer allowed out of their homes. Being quarantined is not often welcomed.  Sometimes food runs out and no-one brings more. To avoid their families being stigmatised by the local community some patients arrive at the ETC's providing false addresses to protect those left behind.

But maybe the tide has turned. Yesterday there were 7 new Ebola cases in Sierra Leone down from 111 at the peak on November 9th 2014.

Until January 21st 2015:  7,923 confirmed cases and 2,788 deaths.

Que Sera Sera

This time last year I was preparing for my second Christmas in Tanzania searching the market for an elusive chicken willing to be sacrificed and roasted. I missed the crisp winter nights at home, the festive lights, the parties and Billy Idol blasting out in shops crammed with food, gifts, clothes and a billion other material things that seem indispensable on December 25th. But there was something to be said for the simplicity of being gifted a pile of mangoes and a packet of cashew nuts. Of not having to cook a meal that covers a dining table and is left half uneaten. No need to buy bigger better noisier presents or watch the Queen's speech or play games that end in stony silences over the evening turkey buffet. Where thanks are given to one God or the other for the blessings of family, health and income. Mangoes had never tasted so good.

I loved being back in the UK. The supermarkets, dirty late night take-away's, fancy toiletries, Friends reruns, efficient transport networks and holidays. Having family and friends who know you and love you despite that, who you can confide in or conspire with because you speak the same language and share a history. Having access to an endless supply of entertainment and distraction. In the last few months I tried bikram yoga, zumba, joined a running club, dating apps, had painting and guitar lessons and honestly, it's exhausting. All of the choice we have, decisions we face, and questions we feel obliged to have the answers to. What's for dinner? What am I doing on Friday? Who am I seeing at the weekend? Swipe right or left? What are my future plans or why don't I have any...? I told my Tanzanian colleagues that they were the lucky ones in some respects. That there are different challenges and obstacles in life whether you live in Africa or Europe. But who would believe me with my nice clothes, money, big house and a one-way ticket back to London. I wouldn't and they didn't.

So, six months of being back home has gone by in a flash. Full to the brim of family, old  friends, new friends, indulgence and extravagance. My next adventure is here and in 2 weeks I will fly to Sierra Leone with Save the Children to work in the Kerry town Emergency Treatment Centre. The plan is to stay for 6 months as their lead in-country pharmacist helping with the current ebola outbreak. Yes dad, if it makes you feel better I will always wear latex gloves and no mum, I won't go jogging on my own....

"He knows not where he's going,

 For the ocean will decide.

It's not the destination,

It's the glory of the ride."