Andy Dennis and Anna Simon

EBOLA

behind the mask

Uitgeverij Aspekt

EBOLA

© 2018 Uitgeverij ASPEKt

© Andy Dennis and Anna Simon

Amersfoortsestraat 27, 3769 AD Soesterberg, Nederland info@uitgeverijaspekt.nl

http://www.uitgeverijaspekt.nl

Cover design and support throughout the production of this book:
ARRIS
www.arris.co.uk

Inside: Salihanur Akpinar

ISBN:97894633846929

ISBN paperback: 9789461539458

All rights reserved. No reproduction copy or transmission of this publication may be made without written permission.

This book is dedicated to the people of Sierra Leone whose lives were touched by the tragedy of Ebola.

Sierra Leone

Simplified plan of the EMC in Kailahun. Shaded gray area is the High Risk zone.

Table of Contents

Foreword

Introduction

Sunday, November 30, 2014

Anna

Sunday, November 9

Anna

Monday, November 10

Anna

Tuesday, November 11

Andy

Wednesday, November 12

Andy

Thursday, November 13 – Second day of training

Andy

Anna

Friday, November 14 – Briefings

Anna

Andy

Saturday, November 15 – travelling to Freetown

Andy

Sunday, November 16

Anna

Andy

Monday, November 17

Anna

Andy

Tuesday, November 18

Anna

Andy

Wednesday, November 19 – Starting work

Andy

Anna

Andy

Thursday, November 20

Andy

Anna

Andy

Anna

Friday, November 21

Anna

Andy

Saturday, November 22

Anna

Andy

Sunday, November 23

Andy

Anna

Monday, November 24

Andy

Anna

Tuesday, November 25 – Death

Andy

Anna

Wednesday, November 26

Andy

Anna

Thursday, November 27

Andy

Anna

Friday, November 28

Anna

Saturday, November 29

Anna

Andy

Sunday, November 30

Anna

Andy

Monday, December 1

Andy

Anna

Tuesday, December 2

Andy

Anna

Wednesday, December 3

Anna

Thursday, December 4

Andy

Friday, December 5

Anna

Saturday, December 6

Anna

Sunday, December 7

Anna

Andy

Monday, December 8

Anna

Tuesday, December 9

Anna

Andy

Wednesday, December 10

Andy

Anna

Thursday, December 11

Andy

Friday, December 12

Anna

Saturday, December 13

Anna

Andy

Sunday, December 14

Anna

Andy

Monday, December 15

Andy

Tuesday, December 16

Anna

Thursday, December 18

Anna

Andy

Friday, December 19

Anna

Saturday, December 20

Anna

Tuesday, December 23

Anna

Wednesday, December 24

Anna

Thursday, December 25

Anna

Andy

Saturday, December 27

Anna

Sunday, December 28

Anna

Monday, December 29

Andy

Tuesday, December 30

Andy

Anna

Wednesday, December 31

Andy

Anna

Andy

1 year later

Andy

Anna

Epilogue

Kailahun

Sierra Leone

Acknowledgements

Glossary

Notes

Foreword

The Ebola outbreak in West Africa was the worst public health emergency of modern times. But the world was slow to respond, and the consequences were dire.

Whilst much of the world recoiled in fear as images of the growing crisis were beamed across the globe, there was a small army of fighters preparing to head straight into the danger zone. They were doctors, nurses, psychologists, epidemiologists, laboratory staff and logisticians – to name just a few. They joined forces with the national medical staff, whose brave efforts were simply not enough for an outbreak that was already out of control. More than 500 West African health care workers died of Ebola in Sierra Leone, Liberia and Guinea.

I started covering the outbreak for BBC News towards the end of March 2014, when the medical charity Médecins Sans Frontières declared that an “unprecedented” Ebola epidemic was underway. By July I was reporting from West Africa’s first Ebola treatment centre in the remote forested region of Guéckédou, South East Guinea where the outbreak began. I have never experienced such palpable fear as when I visited one particular community there. It hung thick in the air and was clear to see on so many people’s faces. It’s something that will stay with me for a very long time.

It’s difficult to over-state the challenge those responding to this outbreak faced. As well as fear, there was a great deal of mistrust, suspicion and denial about Ebola, particularly in the early months of the outbreak. This was compounded by a lack of information about the virus and how it’s spread. On that first trip to Guéckédou, I travelled with medics and communication teams into a village that had suffered a spate of mysterious deaths. They spent time explaining to residents what Ebola was and made it clear – with the help of a recent Ebola survivor – that the virus was not an automatic death sentence. Within an hour, people had started bringing out their sick relatives. There were many of them that day.

During my various deployments to some of the worst affected areas between 2014-2015, I reported from 9 different Ebola treatment centres. We always stayed in the low-risk zones, which were a safe distance away from sick patients. We’d watch medical staff carefully step into their personal protective gear, and disappear into the high-risk areas, where many people were dying.

I interviewed dozens of health workers to find out what life was really like for them behind that mask. How did it feel seeing so many patients who were extremely unwell and knowing that the help you could give them was limited to supportive treatments? There wasn’t – and still isn’t – a proven cure for Ebola.

At the time those medics I spoke to were stoical and practical about the job at hand. Their general response was: “we just have to get on with it and do the best we can for patients”.

It must have been difficult for them to try and process these extraordinary experiences whilst they themselves were still so close to the crisis.

In Ebola: Behind the Mask, Andy Dennis and Anna Simon take you right inside those hot claustrophobic Ebola treatment tents. Through their vivid accounts, you sit with them at the bedsides of patients they cared for.

Among them; 2-year-old little Kadiatu who was all alone as she fought for her life, Alimany the once strapping young Chelsea supporter, and 9-year-old Osman and his father – battling Ebola alongside each other. We see each of them through Andy and Anna’s eyes, not just as numbers in a list of grim statistics, but as people who had once loved, laughed and lived.

The medics who fought Ebola are modern day heroes. In particular, as Anna and Andy point out, the hundreds of West African staff who fought the hardest, and paid the heaviest price.

The stories Anna and Andy share about their experiences and the people they cared for expose why the world must never allow a tragedy like this unfold again. It chronicles unimaginable fear, loss and chaos, but also shows great humanity, bravery and love.

Tulip Mazumdar, Global Health Correspondent, BBC News

Introduction

Andy Dennis:

Alimany the midfielder died last night. A young man in the prime of his life robbed of his future... I take a walk over to a secluded corner... Here I stand and stare into space. My thoughts and emotions swirl and, as often occurs here, I find myself with a deep sense of sorrow.

I have to collect myself quickly as this place is about the living and I have blood samples to collect.

This book tells of the personal experiences of Andy Dennis and Anna Simon in Sierra Leone working for Doctors Without Borders / Médecins Sans Frontières (MSF) during the Ebola outbreak in 2014. It is based on the personal journals that they kept; and their combined different backgrounds and personalities gives a diverse insight into events as they unfolded.

In the four to five weeks that they worked in Kailahun, a remote province of Sierra Leone, they cared for more than 150 Ebola patients, assisting them in their recovery or ensuring a dignified death. They lived and worked in Kailahun but are not experts on West Africa in general or Sierra Leone in particular nor do they intend to give a full overview of the development of the outbreak, the response of the Western world or the efforts of the various other aid organisations.

Twenty-five patients that they cared for in their work are highlighted to give the story a personal touch. After all, they are the human faces engulfed by this crisis. The names of the people involved were changed, for privacy reasons, but their stories are true.

MSF and their call for doctors and nurses

MSF is an international medical emergency aid organisation whose goal is to provide medical care in areas where people have very limited or no access to it. It is active in more than 60 countries, often in areas that are hardly reached by other aid organisations: war zones, displaced populations, natural disasters or outbreaks of infectious diseases, or a combination of those. The central principle of MSF is that it remains neutral and impartial, and will help people irrespective of their background, religion or political preferences. This independence is strongly guarded. Doctors, nurses and other personnel are usually sent on missions of 9 to 12 months. Exceptions to this include emergency situations such as an Ebola outbreak or a natural disaster. In those cases, MSF can send the first people and supplies within 48 hours, to start up a rescue effort.

In the past, MSF has gained expertise in the response to the usual small, contained, Ebola outbreaks, for example in Congo. It has the protocols ready and a list of experienced doctors and nurses who can be sent to such an epidemic within a short period of time. MSF responded rapidly to this outbreak once the disease was recognised but this time the epidemic grew rapidly to unprecedented size. MSF sent more and more people, built more Ebola management centres and was active in keeping the world informed about the huge scale of the problem, to raise awareness that more help was needed.

By the end of September 2014, MSF needed so many new aid workers that it started to recruit doctors and nurses from outside the organisation. That is not a first: for example, specialised surgeons are sent to established MSF missions in war zones, to perform surgery for two to three weeks.

However, the scale of the call for help in The Netherlands, and especially the publicity surrounding it, was remarkable. Everything about Ebola became big news. The Dutch Minister of Health sent a letter to all Dutch hospitals in support of MSF, asking hospital directors to enable their employees to go if they wanted to. The requirements for doctors were straightforward: at least two years’ experience as a medical doctor, experience in supervising others, a good knowledge of the English language and the ability to work in an international group of people. Desirable qualities were knowledge of contagious diseases, having worked for an aid organisation before or experience with medical care in a tropical country.

Andy Dennis

Andy has been a qualified nurse since 1995, prior to which he was a Royal Air Force Medical Assistant. He left the RAF in 1991 after the first Gulf War having decided that if he were to be in conflict situations again it was going to be in a humanitarian rather than a military role.

He has spent most of his career as a nurse working in the British National Health Service, predominantly in critical care areas such as Emergency Departments and Intensive Care. In 2004 he watched the global response to the Asian Tsunami. He stood in awe of one particular organisation and by June 2005 he was working as a nurse with Doctors Without Borders. His first mission was in Northern Uganda caring for people displaced by conflict with the Lord’s Resistance Army (LRA).

Andy has subsequently worked in South Sudan on two occasions. In 2008 he was in Yambio near the border with the Democratic Republic of Congo where he was helping to set up Primary Health Care clinics in two remote areas. This mission was also affected by violence perpetrated by the LRA; indeed, two people were killed in an attack on one of the clinics in late 2008. In 2013 Andy ran the nutrition programme at Leer Hospital in the North of the country. This Hospital had stood for 25 years, before its destruction a matter of weeks after he left in January 2014. He now works in the Endoscopy Department at Harrogate District Hospital, UK.

Anna Simon

Anna is a consultant in internal medicine and infectious diseases. She works in the Radboud University Medical Centre in Nijmegen, The Netherlands, combining patient care with scientific research and teaching. Her specialist subject is very rare hereditary disorders in the immunological field. She lived and worked in the USA for two years doing post-doctoral research in 2006-2007 but she had never worked in patient care outside of The Netherlands. At the beginning of October 2014, Anna responded to MSF’s call for doctors and nurses to volunteer to work in the Ebola epidemic, which made headlines in The Netherlands, and she was accepted.

Sunday, November 30, 2014

Anna

On the stretcher is a man of about 30 years of age. He groans a little but does not respond when Amara, the community health officer (CHO), asks him his name. He arrived yesterday, at the end of the afternoon, in an ambulance from Freetown (around seven hours drive from Kailahun). Of the five other patients in the ambulance, one had died en route. None of the other patients knew his identity.

I squat down next to the bed, carefully avoiding the pool of vomit on the floor, and not too close to his face in case he vomits again. The man’s face is sunken and there is dried blood on his lips. I take hold of his arm. Through two layers of gloves I can hardly feel the weak, rapid pulse. The patient turns his face towards me when I touch him but he does not make eye contact. Amara has put a thermometer in the man’s armpit: 39.2 degrees Celsius. I put my hand on his stomach. The slightest touch is obviously very painful. In his diaper I see diarrhoea mixed with blood. Officially, we do not know whether the patient has Ebola or not – the test result will come back in the afternoon – but I do not doubt that the test will be positive.

Slowly, I get to my feet. Amara and I exchange a knowing look from behind our safety goggles. I shake my head. “It’s too late for him, we will just have to give him more pain medication and keep him comfortable.” Amara nods, and with the help of Sheku, the nurse, he sets to work to clean the man. Sahr, the sprayer, stands at the ready with his CHLORINE spray to decontaminate my gloved hands. After that, he cleans the vomit from the floor. Meanwhile I leave the tent and walk to the fence that separates the ‘High Risk’ and ‘Low Risk’ areas. I call for a medic. Quickly, a nurse walks up to me from within the Low Risk area. I ask her to prepare a syringe with morphine for pain and also something to help his nausea. Back inside the tent, I assist Sheku to prop the man up in bed, to see whether he can manage a drink. Amara is already helping the woman in the next bed. A couple of minutes later, a call from the fence: the medication has arrived.

Calmly, I get up and I walk slowly to the fence to collect the syringes. In full ‘personal protective equipment’ (PPE) inside the High Risk zone the last thing you want to do is trip and fall, or hit your head against the wooden beams, which were not built with tall Dutch women in mind. The temperature inside the PPE rises quickly, especially under a bright sun, even though it is not yet ten o’clock in the morning. I can feel the sweat trickling down my back, my socks squelch inside my boots. We were trained never to hurry inside the High Risk zone of the Ebola Management Centre, whatever the situation.

Back at the bedside, I give the man two injections in his upper leg, and immediately place the needles in a special safe container. That is all the time we have for the man at present. Amara, Sheku and I have been at work in our PPE in the High Risk zone for more than ten minutes already. We are tasked to see and help out 14 more ill patients before the hour is over and our time will be up.

Working inside the High Risk zone, you focus one hundred per cent on your job. Only when I return to the Low Risk zone and am more comfortably dressed in fresh surgical scrubs do I have time to sit down and rest. That is when my thoughts can wander a little. Sitting down with a bottle of water in the shade of the medical tent I think back to the last Sunday I spent at home, before leaving for Sierra Leone. That was only three weeks ago.

Sunday, November 9

Anna

I’m in my study, gazing across the roofs of Nijmegen. I have been working since the early morning. Now my suitcase for Sierra Leone is packed, I can use the rest of the day for my ‘work’ to-do list – the list of things that need to be done to leave my ‘normal’ work in order. Writing letters about patients, cancelling appointments for the next two months, working on research projects, delegating teaching duties and cleaning up the dreaded email inbox.

Next week at this time, I will be somewhere in Sierra Leone. I think back to how I got to this position. As infectious disease specialists, my colleagues and I had been aware for some time of the growing Ebola epidemic in West Africa. Since the beginning of the summer, preparations have been made in our university hospital, the Radboud University Medical Center in Nijmegen, to enable us to look safely after a patient with suspected Ebola. My colleague Chantal coordinates this effort and, since we share a room at the hospital, I have followed developments as they happened. At the end of August, we started the actual training in the use of protective equipment.

On Monday September 22, after months of polishing up the details, the hospital Ebola protocols were completed and approved. As if it was meant to be, that same day our first suspected Ebola patient arrived and the protocols were put into action immediately. I was part of the team of doctors and nurses ready to care for him in strict isolation in a blocked off wing of our Infectious Diseases ward. But my turn only started on Tuesday evening, after finishing my outpatient clinic for the afternoon. The patient was not very ill. The results of his first test for Ebola had already come back negative, and he had tested positive for malaria. There was no reason for me to enter the patient’s room, he was doing fine, so I did not need to put on the PPE (personal protective equipment) this time. During my shift, the long-awaited results from his second Ebola test came in: the patient did not have Ebola. All that was left for me to do was to give him and the nursing team the good news and end the strict isolation protocol.

Ebola and this epidemic

In brief, what is Ebola? The Ebola virus causes a disease characterised by fever, diarrhoea, vomiting, muscle ache and other symptoms. Just like any other viral disease, the combination and severity of the symptoms can vary drastically from person to person. As in influenza, for example, which causes one person to take to his bed with a high fever for a week, while the next gets by with three days of slightly raised temperature, muscle aches and general malaise.

Some patients with Ebola suffer from a few days of fever, diarrhoea, vomiting and muscle aches, before they start to recover spontaneously. Others have a more severe disease course; they get progressively ill, weak and bed-ridden. They suffer from increasing pain in their muscles, joints and stomach, and deteriorate rapidly. In the end stage of Ebola, they can experience internal bleeding, for example in the stomach, gut or lungs. Sometimes, they suffer from annoying, unstoppable hiccups – we don’t know exactly why that happens. These are clear signs of the deadly form of the disease. Some people die quite suddenly.

It is hard to predict who will do well and who will not. The elderly, very young children and pregnant women have a high risk of death. But young twenty-somethings, who were completely healthy before, can also die within a few days.

Perhaps some people can be contaminated with the Ebola virus while they show little or no symptoms. That happens in almost all infectious diseases, from the common cold to the Q-fever bacterium. We suspect so, but no evidence for this has been collected as yet.

In the past 40 years, since the first description of the Ebola virus, there has been only limited research into the characteristics of the virus or the disease it causes in humans. This has to do with the fact that it only strikes in remote, poor regions of Africa. Every year, until last year. small Ebola epidemics occurred, particularly in Eastern and Middle Africa. Of course, it is not easy to conduct scientific research on this deadly virus.

This outbreak started in December 2013 in Guinea. It took a couple of months before it was clear that the Ebola virus caused it. This disease had never before occurred in West Africa. By the summer of 2014 the epidemic was spreading rampantly, especially in the border area of the three countries of Guinea, Sierra Leone and Liberia. In September and October 2014 when a number of cases ended up in the Western world and the epidemic became more and more out of control in West Africa, Ebola finally gained prominence in the world news.

Through Chantal, I learned early on that MSF was urgently looking for experienced doctors and nurses who were willing to work in one of their Ebola Management Centres (EMCs) in West Africa. I thought they would have trouble finding anyone. Who has “experience” in Ebola? But when I heard that two nurses from our department were planning to apply, and MSF’s appeal reached the national news, I started to consider it more seriously myself. I don’t have a partner or children and no dependent relatives, which makes the decision easier.

Finally, after a couple of weeks of thinking about it, mostly in secret, on Friday October 10 I decided to follow my heart. The first step was telling my colleagues at our weekly meeting. “I hope you won’t burst out laughing, but I have been thinking about it, and I want to get in touch with MSF, and put in an application to work as a doctor in an Ebola centre – if you agree to it.”

I really thought they would have laughed: Anna, going to Africa? I have never even been in a tropical country and my daily work is far removed from tropical diseases. But they responded positively.

That same evening, right after work, I sent a carefully formulated application email to MSF. If I’m totally honest, at this point I was still secretly hoping that they would reject me: that would have meant I had done my best and I didn’t really have to go and could stay here in my comfort zone.

But my application to MSF was received favourably. I was invited to an interview, had a psychological assessment and was accepted within three weeks of that first contact. All that remained unclear was the timing. The MSF coordinator promised to let me know the options by the first week of November.

On Tuesday afternoon November 4 I was busy with my outpatient clinic but between patients I couldn’t stop myself from checking my email. A message from MSF. Two options: either leaving in March or leaving on November 15 because someone has had to withdraw at the last minute. Leaving in ten days time! Which would mean starting the training in eight days time! My heart pounded in my chest as I quickly closed the email. Three more patients to go, no time to think about it now, these patients deserve my full attention.

Three quarters of an hour later, when I finished my clinic, I started to realise what this meant. If I said yes, I would be boarding a plane to Sierra Leone in 10 days time! By this time, I really wanted to go. I thought I should be able to get everything organised and I would actually leave less work behind for my colleagues now than if I left in March. My superiors were also overwhelmed by the short notice but their support was clear from the start. On Wednesday November 5, I received the go ahead from my department, and I let the MSF coordinator know that I was willing and able to fill in the November 15 departure spot.

This left me with five working days and two weekend days before the start of the training followed directly by the mission to Sierra Leone. During this week, emails from several departments of MSF kept dropping in – containing briefing documents about the country, the mission, the insurance policies, forms that needed to be filled about my health, my contact information, a visa application, lists of necessary vaccination, information about the training in Amsterdam and flight details.

Meanwhile, my regular work continues as if nothing had happened. This forces me to think about something other than MSF and Ebola, which is a good thing. The to-do list gets longer and longer, and I work long evenings to get everything sorted.

I’m fully supported by my hospital: they grant me paid leave. All my colleagues and others in the hospital respond in a positive way. “You actually look more relaxed than you did last week,” a colleague told me. He was right. I felt better now that the time of waiting and insecurity was over.

Yesterday I went into town with my shopping list. I’ve had all kinds of advice from my colleagues with experience of working in the tropics and from MSF, about what to take. Today, my suitcase is practically ready. This time next week I will be in Freetown.

Monday, November 10

Anna

A regular working day – but not really. In between seeing some unsuspecting patients in the outpatient clinic, I get seven vaccinations, including yellow fever, tetanus, and hepatitis A, and make copies of documents I need for the journey.

Several colleagues ask, “Why are you going?” I had that same question from some friends last weekend. For me it is more relevant to ask, “Why wouldn’t I?” Help is desperately needed, even more than money, and I may be qualified to provide that help. I also look at it in reverse: what if there were some deadly illness going around in my own country and for some reason the healthcare system had broken down and couldn’t handle it – I would wish that people from other ‘safe’ countries would be prepared to risk their lives to come and help us. So, I should be willing to do the same, as I may be able to in this case.

Around noon, I have to deliver a lecture for second year medical students. They are in the middle of a teaching course on Infectious Diseases. One of the lecture slots in the series is always left open, to be filled in last minute with a topical subject. This year, Ebola is an obvious choice. The large lecture hall is filled with between 300 and 400 young students.

Chantal starts off with a good presentation on the medical background of Ebola, about the epidemic and the organisation of the care of potential patients in The Netherlands. The students in the audience listen attentively. But afterwards, the only question comes from a female student in one of the first rows: “Which part of this do we actually have to know for the exam?”

Chantal and I exchange exasperated glances, but we control ourselves: we tell her to check that with the course coordinator. We suspect that there are a lot of students in the hall who are more mature and who are ashamed of their colleague’s attitude.

Then it’s my turn. I have not had time to prepare slides, it will be an off-the-cuff story. When I start by telling them that this Saturday I will be stepping on a plane to Sierra Leone to work for MSF, you can hear a pin drop in the lecture hall. I tell them what my work will be in an Ebola Management Centre and explain to them how such a centre works, using a picture from the MSF website. I talk to them about why I have chosen to apply for this, despite the risks.

Afterwards, I invite the students to ask questions. To break the tension in the room, I can’t resist telling them that I think that this will not be part of the exam. This causes some sniggering. A number of serious, interested questions follow. Whether I’m scared that I will get Ebola myself. What my family thinks of my decision. At the end, unexpectedly the students give me resounding applause. A nice gesture from them, which touches me. That afternoon, a group of the students send me an email, to thank me for making them think and to wish me a successful and safe mission.

At the end of a long day, I’m tired. There is so much to get ready in such a short time, for the trip, for my personal affairs at home, for the work I leave behind – it drains my energy. Due to my fatigue I am somewhat bad tempered on the phone this evening with my parents, my brother Huib and my sister-in- law Mireille, but I know they understand me.

Every drawback has an advantage: the hectic but short time for preparation is extremely intense, but will also pass very quickly.

Tuesday, November 11

Andy

It is ten o’clock in the evening in the Meininger Hotel in Amsterdam. I am going to bed in a few minutes, as tomorrow is a big day. I will be starting my “Ebola training” prior to heading to Sierra Leone on Saturday. I have spent much of the evening mulling over the events of the last few weeks and months.

In mid 2014 the world finally woke up to the Ebola outbreak in West Africa. I was losing sleep and finding myself unable to concentrate. How could I live with this situation as a distant voyeur when I have skills and knowledge that could help?

I had just started a new job at the Harrogate District Hospital’s Endoscopy Department in August 2014. By the end of September I was in my boss’s office after asking if she was free for a chat. “Lorraine, I have something I need to ask you” I began, before telling her the story of my sleepless nights and how I had a nagging sense of unease and frustration. “I am really suffering watching all of the news reports about Ebola and not being involved in the response. I have decided to just come out with it and ask you if there is any way I can have time off work for a mission.” I explained that it would be a one-month mission but there would likely be a period of monitoring afterwards to ensure I am disease free. In my heart I hoped that Lorraine would say yes but I was acutely aware that she has responsibilities that may make it impossible for her to allow me to go. She listened intensely as I explained my request and then offered an immediate “yes.” She followed this with a very moving explanation of why she believed this was an important thing for her to support both as a person and as a manager in our hospital.

I left the office feeling both elated and nervous. I was one step closer to my next mission. Later I called MSF to let them know that I had approval from work and asked that they actively look at matching me to a mission in West Africa.

The rapid turnover of staff in the missions is a nightmare to manage for the human resources team in the MSF offices. Due to the intensity of the work and the inherent risk of Ebola, missions for expat medical personnel who work inside the Ebola Management Centre (EMC) are limited to four or five weeks duration instead of the usual six months. The number of people required to staff the projects adequately is therefore immense. Finally and by email on October 20, 2014 I was offered a four-week mission in Kailahun, Eastern Sierra Leone.

Harrogate District Hospital is a close-knit community and I know many people who work there. Each day I was asked questions by people who had heard on the grapevine that I was going to work in the Ebola outbreak and wanted to express concern. “How long?” “Where?” “Will you be safe?” “What happens when you return?” Right up until I leave for Holland I am finding out information about the mission. The question about what happens at the end of my time in Sierra Leone will no doubt be answered in the next few weeks. There are many ambiguities about the 21-day monitoring period and its implications for coming back to work post mission. All will become clear, I am sure.

So here I lay in the Meininger Hotel, one and a half months down the line contemplating the coming weeks. I have been saying farewell to people for the last three weeks and today at Leeds Bradford Airport I said goodbye to my Mum and Dad and Tracey, my long-suffering girlfriend. I know that this is a lot to put them through, so many people are dying in this outbreak and the reports are all over the TV. There is little escape from the tragedy that is Ebola.

I try to clear my mind, I relax on my comfortable bed and turn off the light.

Wednesday, November 12

– Ebola training from MSF in Amsterdam

Andy

The night is rather unsettled, the change of environment, the saying goodbye, the anticipation of today, missing Tracey. It all adds up to disturbed sleep. I leave the room and go down for breakfast in the morning about quarter past seven with the plan to be out of the hotel by about half past seven. I soon identify other MSF people, which is both reassuring and interesting, there must be an MSF look! More likely it is the mixed group of people dressed in many different ways and the varieties of accents that make me suspect I have found my new colleagues. We leave the hotel as a group and head towards the bus station on our way to the MSF Ebola Training Centre.

An unexpected surprise is that one of the participants is a psychologist that visited the hospital in Leer South Sudan when I was there in 2013. Also Jeff, my former boss from South Sudan, is on the bus. It is very nice to see them as it is always a little strange meeting a whole new bunch of people and a familiar face just takes the edge off the nerves. Jeff and I have a quick catch up before getting to the Ebola Training Centre. Inside the Ebola Training Centre, a fully set up treatment area is ready for us with High and Low Risk areas, manikin patients, chlorine points for hand washing and decontamination, dressing and undressing stations and everything else we need for our training.

The day is taken up with lectures and practical sessions in the simulation area. Lectures cover the Ebola epidemic, the management of the disease, the risks and how we can protect ourselves and how an EMC (Ebola Management Centre) works. In the afternoon, there’s a practical exercise in the simulated EMC, to practise dressing and undressing in the personal protective equipment (PPE). One very important point that is emphasised is the need to respect and appreciate the National Staff. The Sierra Leonean staff have been working in the EMC in Kailahun since June and have been caring for and burying their colleagues, family and friends since then. The last thing they need is new expats going there every four to five weeks with totally new ways to do everything.

The other trainees seem like a nice group of people and we are slowly getting to know one another. Most of them are heading to Kailahun. There are of course one or two personalities that seem rather domineering and opinionated but I guess that’s pretty normal.

We train until about six o’clock then eat pizza and enjoy a beer back at the hotel bar, chat and get to know each other in a social setting.

How contagious is Ebola actually?

Not very much. Especially compared to other viruses, for example the regular influenza virus. The Ebola virus cannot be spread through the air. It is destroyed by exposure to soap and water, or to water with added chlorine. Even UV-light from the sun is enough to kill the virus. And it is not able to pass through intact skin.

To get ill from the virus, you have to be in direct contact with body fluids from someone who is ill from Ebola. Diarrhoea, vomit, blood, sweat, tears, urine – every kind of body fluid. Next, the virus has to enter your system through either a breach of your skin, or through your mucosa such as eyes or mouth when you subconsciously touch your face and rub your eyes or touch your lips. If you get contaminated blood on your hand but directly clean it with water and soap without touching your face, nothing will happen providing, of course, that you do not have any cuts on your hand.

There are many safety measures to prevent contamination. The most effective measure is frequent hand washing, with water and soap, alcohol hand gel or chlorine water. This sounds easy, but it can be harder than you think in a country where running water is a luxury. Another safety measure is the instruction to keep a distance of 2 metres from an Ebola patient, and to avoid touching him. That distance is enough to keep you out of range of any vomit or coughing; the bigger drops of vomit that could potentially contain virus particles will fall in a range of about 1 metre.

In the EMC, there is an area called the High Risk zone where suspected and confirmed Ebola patients are cared for. Here, more strict safety protocols are in place. Everyone will have seen it on TV or on the internet. Anyone entering the High Risk zone dresses up in personal protective equipment (PPE). This covers the entire body and consists of an overall, an apron, a facemask, a hood to cover your head, double layers of gloves and finally big safety goggles. Not an inch of skin remains uncovered. Of course, you cannot maintain the safe distance from patients when caring for them. Patients need to be washed, vomit and diarrhoea needs to be cleaned up and patients have to be tended to after their death. All circumstances that will put you in close contact with the virus. Dressed in PPE the outside of your protective covering will become contaminated with virus. In between each patient-related action, you wash your double gloved hands in chlorine water. This also offers protection for the patients: even in the part of the EMC where every patient already suffers from Ebola, you do not want to spread regular bacteria from one to the other.