It’s been a week of change here, so not much writing done. I’m reflecting back on various aspects of what has happened.

I did a night shift some nights ago in Lakka with U, a U.K. doctor early in his training. He’s not a member of the NHS team, having organised to go to Sierra Leone during annual leave. These are the people I really admire; there was no razzamatazz for him at the airport, he’s paying his own way, no lengthy preparation by the army, he was on his own. It’s not ideal though; he is very early in his medical career and vulnerable to overreaching professionally, and UK-Med would not recruit doctors at this stage at least for this first wave. The NGOs make their own decisions and here at Kerrytown we are joined by a number of doctors at various stages, from only 2 years from qualification to very experienced, and only the odd consultant. Many of the juniors are taking an alternative path to career development, and I think this is laudible, as the experience they gain goes beyond clinical professional development, to becoming rounded as responsible people with experience of teaching and leading. I wish U well, he’s a bright man who deserves success. I will speak in the future about the insane world of NGOs. Save the Children are pretty amazing really, and have pulled something out of a very difficult situation for which they were initially criticised; the pressure from the government to get the ETCs up and running is enormous given the publicity and huge financial undertaking, however to open too quickly has been shown to lead to chaos and the death of health care workers from Ebola, which is unacceptable.

So I’m polishing this off from a posh beach hotel opened a year ago. It would have been empty had it not been for Ebola, but has become instead the nerve centre full of people on computers having strategic conversations, organising supplies, problem solving, doing HR and a myriad of other things. They have to be incredible flexible and adaptable, and create solutions at scale in days. There is a lot of patience being applied as well, and we all need to remember that nobody really knows the best way to treat this epidemic.

On the way out of the night shift at Lakka we passed a large group of young men waiting to be interviewed for hygienist jobs. The hygienists have in some ways the most dangerous job, coming into the red zone to clear up rubbish, blood, vomit and diarrhoea, and the bodies of the patients who die. The latter is a careful process of double bagging without spreading Ebola, as at the point of death they are contain the greatest load of virus particles leaking from body fluids. The extra protection they get is that they wear washing up gloves instead of thin surgical ones.

Unemployment runs at 90% here; literacy at 43%. So there were many applicants but with a low educational level, looking for what is by local standards very well paid work with a large meal in the middle of the day. The danger is there, what goes unreported are the number of national health workers getting Ebola from work, and the accusation has been levelled that the international community only responded in a big way once some rich nations’ doctors and nurses got infected. Sadly one of our hygienists died in the ETC a few days ago. He had been off with a foot injury, and we will never know how he acquired the infection, whether from working at the centre or outside.

So a group of young, uneducated men come in to do a dangerous job. Milos, the chief nurse at Lakka is very thorough at teaching them how to use PPE properly and shouts very loudly at any dangerous behaviour. However he is such a charmer they love him despite the tellings off. What I find frustrating is the continued attitude outsiders to Africa have about getting things done. “Welcome to Africa” is the response, about things taking a long time, and about workers not working the way you want consistently. So I’ve been asking if education is part of the training. Do these workers even have an understanding of the concept of cells, that their bodies are made up of these, and that viruses attack by getting inside cells, multiplying and then the progeny being released as cells break down? The answer is no, they are just told what to do. At my next deployment I am going to ask if I can do some training sessions, as a basic understanding may promote a continuing sense of carrying out the procedures in a safe way. I’ve heard from those NHS workers at other ETCs about to open, that the NHS staff have been working hard on this.

The NHS team at Lakka has moved to the ETC at Kerrytown run by Save the Children . In the hiatus 4 of us walked to Lakka beach, a beautiful seaside resort sitting behind a long golden sandy beach. You can see the potential for Sierra Leone as a tourist destination, as long as the people are given ten years without another civil war or deadly viral epidemic to deal with. I’m planning to come back for a holiday with Juliet when it’s safe, it’s such a beautiful country with peaceful, friendly people.

The following day we walked with a sierra Leonian logistician, Michael, into the heart of Freetown, walking along bustling roads past the ministerial building and ending up under the Cotton tree, a vast tree inhabited by fruit bats. It was great to get a sense of what the place is about apart from Ebola. As we walked over one bridge Michael told me its name: Peace Bridge, which marks the place where the army resisted the rebel force during the civil war. Later I saw a beggar, a double hand amputee from the rebel practice of chopping off hands during that terrible time.

Ernest the owner of the Kona hotel in Freetown, took us to the new hotel he is building, in a very posh car. It is being built slowly but on a very grand scale. He took us to his office, which looks like the set of a Bond film where the baddie runs his operations. He was nice though, and casually mentioned he is hoping to run for president.

As I finish this section it is Tuesday. Last Sunday we drove the hour and a half journey to Kerrytown, or to be precise, to a posh beach hotel (Tokeh) that will be home for the remaining three weeks. We went into the ETC and learned their PPE routine: something to get used to is the separate hood and goggles rather than the visor. Each NGO has done its own thing, so you have to learn a new way of donning and doffing, and clinicians talk about this obsessively, as their lives depend on it. Everyone from national hygienists to consultants are very careful.

Yesterday I passed my PPE exam and did a late shift 2pm -8pm. During 2 entrances of an hour I tried to encourage a 2 year old to drink. He was tired from Ebola but not that dehydrated and we were trying to hold off from the trauma of an IV line or an intraosseous line ( less traumatic I believe than it sounds, drilling a hole through the shin bone to place a catheter in the bone marrow , an extremely effective way of delivering fluids fast). He was just miserable and asking for his mother. What a lonely place it must be for him, and none of the other women in the ward seemed up to helping out. All he really needed was a knee to sit on and someone with a cup. My nappy changing skills at least came back to me! In the end the night shift did get a line in and I’m looking forward to seeing him during my night shift tonight.

The setup seems much closer to what we we’re expecting medically. The ETC is adjacent to the military 22 bed unit that looks after national and international health workers. Their lead consultant is an amazing man, having worked with this and other viral haemorrhagic fever outbreaks as a career, and having witnessed at first hand the terrible conditions in Kenema earlier this year. His leadership is direct, clear and patient, another example of the army at its best.

We are working at least alongside, and hopefully with, a large team of Cuban health workers. They are friendly, and will work but apparently some more than others; I don’t think they were given much choice about coming. I’m trying my rudimentary Spanish and hope we can work effectively together, but the handovers between shifts could be improved. The planning before entering the red zone makes the difference between achieving something and just getting incredibly sweaty and hot. You have to keep asking yourself if any action is dangerous, and I have to slow down and do things methodically.

This has probably gone on long enough, and is a bit dry, apologies . Hope to be more eloquent later.