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On the face of it, being a professionally qualified medical officer should guarantee a job on retirement, but working on the General Staff is not the same as working on the wards. So, when I left the Army I was attracted to a broader humanitarian career, and in 2013, I joined Save the Children as their International Humanitarian Director, on the same day that Typhoon Haiyan struck the Philippines. It was a classic rapid onset disaster that the humanitarian community loves. Floods of volunteers and easy fund-raising guarantee success, and I watched incredulously as millions of dollars in aid were turned into shelter and livelihoods and mobile clinics. Nine months on it was a different story when the UK Government's overseas aid department, DFID, asked us to take over the management of an Ebola treatment centre. The West Africa outbreak started in Guinea in November 2013, just as Typhoon Haiyan rampaged through the China Sea, but this epidemic took its time to advance, and even at the start of July 2014 alarm bells were not ringing loudly enough. Then, the US Centre for Disease Control announced that cases were doubling every 20 days, and if unchecked would reach at least 550 000 by the end of the year. Suddenly, airlines cancelled flights to West African countries, and restrictions were placed on the movement of passengers from those countries.
The offer was generous: whatever it costs, the British Army was to build and set up a treatment centre, giving us time to train and then take over the running of it when we were ready. The reality was different. First, the government was very cautious about the risks. While we in the Non-Governmental Organisation (NGO) sector can volunteer to be in harm's way, soldiers are ordered, and there is little appetite to take some risks short of war. The US military deployed more than 2000 troops to build treatment centres, but they were to stay at least one bound clear of any potential cases. The British government was more pragmatic, but restrained direct involvement in patient care to international staff working for the government, and eventually, national health workers who had become infected in the course of their work. It was left to us, an international NGO, to take on the task of running a treatment centre for the local population. This was important on several levels. First, there was a desperate shortage of treatment facilities. Second, international NGOs had largely withdrawn from the affected countries, Sierra Leone, Liberia and Guinea. It was important to establish confidence in the national governments, who were short of all the resources needed to manage the outbreak, and to support local health systems that had by then broken down almost completely. It was also essential that the international health system, which was in danger of failing, should demonstrate that it was capable of responding appropriately to an emergency of such potential concern.
There was just one problem. Save the Children was not yet ready to be a front-line emergency health charity, and although we had recently taken over Merlin, a British health charity, we had no clinical capability at readiness: no people, no policies, no equipment, and crucially, no training. It was not a task we could readily take on, but I agreed to send a recce team which came back 3 weeks later, saying that expectations were very high: the President had started building a treatment centre with our name on it, but the team concluded that we should not get involved. The risks were too high. A period of heated diplomatic wrangling followed, leavened by the emergence of a Cuban medical team to support us, and the promise of volunteers from the National Health Service (NHS) should we succeed. On the 18th September 2014, Save the Children agreed to open a 48-bed Ebola Treatment Centre at Kerry Town, in the western region. It would be fitted out with support from the Royal Engineers, and supported by 22 Field Hospital, who would provide a 12-bed facility for international staff and health workers. We would provide most of the logistic support, would recruit and train some 600 local staff as water, sanitation and hygiene (WASH) staff, provide all domestic and security services, and all in 12 weeks from a standing start.
History overtook us, and as cases increased and panic started to grow, we came under intense pressure to shorten our timelines. Eventually, and against all the odds, we opened to a fanfare of publicity on the 5th November, followed by howls of criticism. We had put together an untested management team and started to work on our plan. The policies could be lifted from MSF initially, but the biggest challenge was the staff. Bringing them together, recruiting locally, putting together a training plan and overcoming a host of language, cultural and practical difficulties proved very challenging. We had the Cuban team, recruited key staff internationally, welcomed the local Ministry of Health staff and set up recruiting centres for our WASH and logistic staff. And we almost managed it, but the opening was a minor disaster, as all planning assumptions went out the door, as we were overwhelmed by walk-in patients. The arrangement had been that we would receive only one confirmed case in our first day, and only receive confirmed cases until we were fully open, but once word was out that the centre would open, there was no way of regulating patient flow except at the front door; but, we had deliberately not put in place the much more complicated arrangements needed to assess and triage suspect cases. On that first day, we admitted nine cases in the end, under the full glare of the world's media, and it subsequently transpired that because of the chaos one of our Cuban doctors probably became the first case of transmission at Kerry Town.
The problems were not confined to us. We asked the police and army of Sierra Leone to put in place checkpoints in order to control flow of suspect cases, and a local doctor, suspecting correctly, that he had become infected, self-referred to the military facility that week. Due to poor communication, he was turned away and subsequently died, but not without denouncing us in the national press. This destroyed the trust that we were trying to build. There was an outcry locally, in the Guardian, on the BBC at home, and in the media in Sierra Leone, and we were accused of dragging our heels. At the same time, as cases increased, we came under further pressure to expand to 80, and then 100 beds, even before we had one ward open. Our staff became intensely demoralised, and at the same time we started to discover major failures in the construction of the facility. Our boreholes dried up; we had to start trucking water and our septic tanks started to overflow.
I decided to deploy and take control to calm things down. The UK government was on the verge of giving up, but it was clear that although we were out of our depth, we had most of the components of capability within reach. We went on to the offensive in the press, asked for more time, reviewed our governance arrangements and asked for help. Experts from MSF helped with a rapid review, and I approached the MoD seeking support from 22 Field Hospital. They were not seeing many patients, but had the very best clinicians that the UK could muster. My team was young, inexperienced and demoralised. It took a week of negotiation, but I persuaded the UK government, at the Secretary of State level, to provide a consultant and specialist registrar to us to mentor and develop our teams. The extraordinary risk aversion shown by our government to direct engagement in patient care was understandable, but not shared by the clinicians themselves. We then embarked on a 4-week turnaround which resulted in us developing the highest level of patient-centred care anywhere in this response. We introduced 24-hour intervention, provided fluid resuscitation round the clock and started treating large numbers of children, who, even when ill with Ebola, are problem patients. If not too sick to move, they spend their time being kids, poking holes in the plastic walls, climbing through windows, turning taps on and off. We had to recruit the less sick patients to care for them, and then during recovery, we started to employ survivors just to manage the kids.
By then we had turned the corner, and by the time we declared Full Operating Capacity (FOC) on Christmas Eve, I think the epidemic had peaked (Figure 1). There were six other UK-funded treatment centres open, but only Kerry Town—the military wing––was taking health workers. A small number of health staff did have to be evacuated, including our Cuban doctor, but the WHO put in place an excellent system to manage that.
There was one further twist to the story however when one of our UK NHS volunteers returned to Scotland at New Year and subsequently became sick, the first Ebola case to be diagnosed on British soil. She is testimony to the extraordinary courage shown by so many volunteers in this response, people who knew the risks but just wanted to help. They are the backbone of the humanitarian system that operates around the world.
So, how did we do? Upfront I will state that I do not think that we materially changed the course of the epidemic, but we did do what we set out to do. We provided the best care we could, we demonstrated that the international community was prepared to respond and we enabled others, not least the military, to manage the risks that they could not contain. In the process, we treated 458 patients and employed 710 staff. In the first few weeks, the patients were all confirmed cases, and mortality was high. That changed, and after Christmas, we saw increasing numbers of suspect cases. That presents its own challenges in terms of infection control and separation. The military eventually did treat a significant number of patients as well, and although they have not publicised their figures, there is one truth that stands out. Patients who are very seriously ill and who present late in their disease are likely to die. The few very sick patients who were flown back to Europe did survive. The air bridge supported by the military gave confidence to international volunteers, and had it failed, the knock-on effect on international confidence might have been catastrophic, because if volunteers from around the world were not prepared to take the risks, these countries would have suffered much more.
At the end of the day, I am still in two minds about whether we should have done this. Personally, it was as satisfying and as challenging, in the end, as any combat or peacekeeping operations I have been involved in, but it was tough. It showed that risk management has many faces, and you will not always be thanked for describing those risks, and they cannot always be managed, however many resources you are able to throw at them. But, it did show that the capability owned by the Army can be used in imaginative ways and that it can be a force multiplier, but only if they are sometimes prepared to work with unconventional partners.
Twitter Follow Michael von Bertele at @vonBertele
Disclaimer These views are solely those of the author and are not intended to represent the views and policies of either Save the Children or the Ministry of Defence. A longer version of this article entitled “Save the Children's Response to the Ebola Crisis” appeared in Pennant, the magazine of the Forces Pension Society, in November 2015.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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