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The Royal College of Psychiatrists Improving the lives of people with mental illness

Sierra Leone

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19/11/2014 10:42:29


Monday 3.11.2014Gloves

Day of meetings in the office. 

People here think chlorine can cause ebola, and thermometer guns take your soul away... 

Ebola is getting worse and worse though - with a 10 fold increase in this area over past month.

There is resistance to the messages about staying away from dead bodies and social distance. People think chlorine can cause ebola, and thermometer guns take your soul away.  


Survivors are really unclear whether they will have any residual effects from the ebola.  As well as the blurred vision and muscle aches, treatment necessarily gives you an induced cerebral oedema.  It's unclear if there is long term sequelae.


The survivors I have met so far seem pretty much ok although terribly bereaved with survivor guilt. They feel stigmatised. They may well have the, possibly accurate, belief that they spread the virus to their family contacts. Ebola stays in the semen for 3 months, so another story I hear is of someone who was told they were clear, but passed ebola to his wife.


Am reviewing some Ebola survivor support documents. It said ‘Congratulations you have survived Ebola” . There is no congratulations in surviving Ebola when many of your family have died; you have lost your job, people think you are a witch - all sorts of complex layers. The survivors really are a suffering group.  Hope we can help them, and get them to help Sierra Leone.  


But so delighted to be able to now give cash to my nurse colleague, Jennifer, tomorrow and green light for clinic set up.


Tuesday – no temperature

Really nice to meet Uncef today, and many NGOs for a meeting on developing mental health strategy for Ebola by the end of the week. Big task but it was really invigorating. If we could just get action from this...

I'm hearing a bit about what it is like in the treatment centres for ebola. There can be excellent caring staff and there can be those who treat people in an inhuman and scared way. Children can become unwell very, very quickly and die soon. Adults can give in, but there are those that battle it.


I was delighted to hand over £5400 in cash to the Connaught nurse led mental health clinic at Connaught today.


Today they tell me that even though my flight is Thursday at about 4am I have to leave Freetown at 2pm on Wednesday in the middle of the training. Such a pain.  Now I don't feel ready to leave - so much unfinished business here...


Have realised some of the things I can do here which I didn't  really realise before like emergency policy response, staff support, training etc.


Last day in Freetown.


First thing is a visit back to the printers. I break all the rules again; share my phone, touch surfaces that I don't know about.  I bathe my phone and arms in alcohol after this. Any time you even come close to someone you need to wash and scrub. You forget not to touch your face and before you know it... ebola panic!

TrainingReally lovely training today to HIV counsellors, social workers, technicians and others. Really receptive audience for psychological first aid. When you delve, they all are affected by Ebola with personal loss and indirect effects on their lives. Many today work directly with Ebola sufferers or with labs where they need to wear PPE.  Psychological First Aid is a lovely tool to get some basic humane care and dignity of the sick, well, dying and the dead.  


Training is my natural home so I always love to be there. I hope I have inspired some of these guys to be compassionate to Ebola sufferers and survivors, and help with the high level of community stress. Leaving behind such simple messages:  No touch, wash your hands, go to hospital if fever or symptoms.

The fear probably comes out of all the imagery of bleeding from every part of the body - including the eyes

Will miss my dear colleagues Istvan and Seddie here, and my friend Carol.  We went out walking and buying fruits. She had a load of lollipops ready for the children - I love anyone who does that!  Such a generous, beautiful person.


Ferry to the airport, and now at the airport hotel. I think if I order food they have to go out and get it. I'm the only one in the whole hotel. I'm acutely aware that last time stayed in the airport hotel here I ended up with malaria.


I still struggle to get a clear vision of goals and imaginative programmes but leave Sierra Leone feeling ok with what small contribution I have made and, if I really was desperate to leave, it would be a failure. I want this programme to work and I want people with ebola to be treated with respect and dignity. I want the survivors to be able to get some income by putting back and helping others and peer support for each other. I want children to be cared for in a humane way and orphans maybe looked after by family and relative or caring survivors if contacts of Ebola. I want the future to be better here in Sierra Leone, plagued by 12 years of war and now literally a plague.


This is a land where touch can kill. Yet there's a lot of human warmth and caring. I say goodbye with no touch – well a double elbow shake with one person which is not quite the same. And still you feel a bit nervous about this.


I remain an indirect contact of  Ebola but it will be clear by the time I get back to the UK. I've been lucky.


My friend Runar is coming and has been coming here for a year now. There is a steady trickle to a stream of new people. There is a Cuban 100-bed unit just opened.  There are over 160 Cubans here. There is the British army new units. The bed capacity is shooting up and is very much needed.


On the map the only district lightly affected has been Koinadougou in the North and predictably the cases now beginning to shoot up.


As I leave, Freetown remains awful for Ebola and the area around.  We've just got to get past this peak. But you look at all the slums around and see how easy this dreadful virus is to spread.  


At least there is great expertise and good will here to deal with this.


Thursday 6.11.2014

No temperature


In fact since I have been here I have gone from 32 to 37.3 degrees. Now I really wonder how accurate these thermometers are.  My 21 days of potential incubation start from today. I need to take my temperature twice a day and call for immediate help if I spike any temperature.


Two and a half hours to check in, temperature screen, health declaration which is surprisingly short. In fact I haven’t had my temperature checked since before the wait to check in 3 hours ago.


Packed flight of locals and us European, Canadian and US lot. During this mission I have met probably most from Canada and USA. Happy to say my home country Ireland has been more than well represented here.  


And yes, they did take my temperature again before entering plane.


Arriving in Casablanca was a big deal. First the stench of the chlorine on the gangway. Then thermo imaging and a load of men in white boiler suits and masks. You certainly knew you were coming from and Ebola region.


Not sure if I'll have much to write after this as I head to Geneva and debrief. I will be interested to see how people react to me in UK. My US colleagues are facing a lot of stigma on return to US. Ebola causes such a panic and fear even when you consider it is still relatively rare even in West Africa. It is very bad luck to get it. The fear probably comes out of all the imagery of bleeding from every part of the body including the eyes.


I now have a 21-day clock to self-monitor for fever and symptoms from today.


Debrief in Geneva- health check up.   And counselling session, which was a nice chat


Am lunching on the shores of Lake Geneva and trying to keep quiet about Sierra Leone in case anyone gets fearful. Someone does ask me where I have come from as we were discussing burial teams.

Sunday 9.11.2014

Temp 36.7


Checked in and ready to go at Geneva Airport. I cannot believe how expensive this place is.


This will be my last entry as I head back to the real world.


I noticed that there isn’t a leaflet for workers who have returned home and the sorts of feelings they might have and secondly a leaflet of FAQs for employers, schools, nurseries, etc. where people like us may face stigma and discrimination.


On the how you might cope after this - I'm less clear what might happen.  From other assignments we know that people have different reactions. Some people just get on with it, some get depressed and miss it a lot.  Others want to talk about their experiences all the time to an increasingly less interested audience.

For me something like this you have to put in a mental box. It is hard to share them with those who haven’t been part of this directly. There is also the pain and tortured feeling that you still would like to be out in the field rather than your main routine job. But you've got to put that aside and carry on with life.

I spoke to a friend of mine from Haiti days. We both missed it but, as she said, it had its time and we must move on. Then she tells me she is moving to Northern Canada to work with teenage Inuit! Global work gets into your system like nothing else.


West Africa will need volunteers for a long time to come - not to mention so many other places. I mention here the volunteer programme of the Royal College of Psychiatrists where a lot of this started for me. There are the THET partnerships and other opportunities for these once in a lifetime experiences. They make you a better health provider and maybe even a better person.


I'll be happy to speak to anyone interested in this kind of work. 


Also, refer to the Volunteering and International Psychiatry Special Interest group of College.

And #psychvolunteer twitter.  




December 2014

19/11/2014 10:37:07

Detergent, chlorine, soap

20.10.2014 Ebola key messages


36.4 degrees

My hands smell so strongly of chlorine. I can't recall how many times I've washed them today.  Thermometer guns are at every building.

Spent the morning at meetings. 

Followed this with a lunch meeting to talk about the recent death of a staff member - and the consequences. I later got to see how at risk I am myself.

The clinic I was in has now been taken apart and burnt.


Later - productive meeting at Unicef.


Then I arrived at the Connaught hospital. This was scary. Arriving at the front gate with lots of people around, I'm aware that people close by have been turned away from the hospital due to the severe shortage of beds.


I'm struck by the realisation that this must be one of the most dangerous places on earth.


It's hard to remember never to touch anyone.




Now low risk contact – official. On contact list.  


Talking to someone doing contact-tracing. People don't tell the truth. Even someone who was quarantined did not tell his wife until nurses were visiting him at home.


Meeting today with nurses who will hopefully be deployed throughout the country. Then dash off to UNICEF to meet with stakeholders from almost all psychosocial input to create a national psychosocial response to Ebola.   

They actually felt that the people in quarantine were there as a result of punishment from God.



Doing what is needed, if a bit dull – working with partners on mental health and psychosocial strategy.  But it's productive and hopefully will help people of Sierra Leone ultimately and very soon.


Documents enable work to happen.


Lot of discussion on survivors, peer support, district plan etc.


I returned to clinic where I had been on Saturday. The holding unit has been burned. But the clinic was pretty much as it was. I'm reassured that it probably wasn’t real contact or at least indirect. A patient died when I was there but not in the direct vicinity. The staff are ok thankfully but the clinic is still closed.  We had been told that the chairs we were on had been burned, but this wasn't the case.


I hear that 75 to 100 people a day are recovered in Freetown at the moment.


My hands smell so strongly of chlorine. I cant recall how many times I've washed them today. And the temp is 37.01 from the laser thermometer gun. Thermometer guns are at every building.


Mammy queen and Daddy kings – these are local wise villagers and potential important community supports.


How to survive Ebola:  Secret is, I believe, copious fluid from the beginning. Maybe up to 5 or 6 litres. You become fluid-overloaded which effects heart, lungs etc. and there's swelling everywhere, but this is way to survive. If not, by day 2 or 3 you don't feel like drinking anything and by day 4 or 5 you're too weak. Usually death will take place by day 6 to 8.  After that you may survive if you've lasted that long. Informally after contact, if you don't get anything within day 8 then you're ok -  probably. For me this is Day 5 – and still no temperature.



Beautiful Freetown day.


I attended a large meeting of Psychosocial, gender, child protection pillar. We used to talk about clusters but now coordination is with pillars.  There's a lot of information missing on cases and a risk that children who are orphans may be lost to services. I hear about problems in the field.


Feedback from the survivor conference . Some harrowing stories are relayed. Lots of survivor guilt and feelings they had caused the spread of Ebola. There are unbelievable numbers of deaths.

Next conference is cancelled as the area is not safe with too much Ebola. We hear a story of 1 survivor who was body bagged while still alive. About 70% of survivors have poor vision and muscle pain. The government is trying to get free health care for survivors.  There is a need for survivors to reintegrate into life and into families. Most are jobless. The experience of being in this treatment centre is quite harrowing.


The Connaught hospitalLater I head to the Connaught hospital. I see three of the nurses who are pivotal to the mental health system. We have an open discussion of the plan and what is needed. I leave by the main entrance again and walk past a corpse on a trolley that is waiting for the burial team. No one seems to be paying any attention to it. Outside again I feel so guilty about wanting to be distant to the people outside waiting to go in.


My driver tells me story of a burial as we pass by a funeral – incidentally the most dangerous activity of all – where the family dug up the body at night to wash it – again highly dangerous and a sure way to get this very, very sticky virus.


The end of the day and a glorious beautiful sunset in a blighted land.




36.0 temp


I will be monitored by a nurse but I'm still low risk contact.

Frustrating meetings this morning.  It is hard to make things happen quickly.


Very nice staff support session at UNDP.  But there is a lot of terror about Ebola and somatic symptoms. Light-hearted but deadly serious at the same time. There is no getting away from Ebola from waking up in the morning to night time.  Lots of insomnia. One lady reported her children are behaving differently, and not eating so well. They're not asking about Ebola but it is everywhere. But we all have to move together and try and lead as normal a life as possible and keep safe at same time. Everyone has stories of people they had lost.



A quick lunch before heading off to city of rest. This is a private donations supported addictions centre at the edge of town. It is very firmly religious based. We arrived as they were having an assembly. Patients or 'candidates' as they were called are actively involved in a religious type affirmation session. The pastor there leads. We are taken aback as he then touches the forehead of every ‘guest” in turn. We are further astonished when he shakes hands with us. This is the first human contact I have had in over a week. He says he doesn't have Ebola and Ebola will not come in because of God. They are no longer accepting admissions is one allowance to Ebola. It has been the only place I have been so far where I haven’t had my temperature taken on the way in. There is a significant addictions problem; cannabis, cocaine, alcohol. Freetown was on a drug route apparently, although nowadays you wouldn't think so.


25.10.2014 a weekend of writing proposals and paperwork.


Went for a walk for first time. It's surreal as the thing that is on everyone’s mind is do I, or do you carry Ebola? The most terrifying thing is if anyone touches you. Even children keep their distance. Lots of dogs around as well – rabies or Ebola – hard to choose that one.


We pass a church and a mosque. Attending either of these is a risky endeavour these days. I certainly wouldn't.


There are lots of market stalls on the way but it is a very subdued atmosphere really.  A few hellos, but no one tries to sell us anything or ask us for anything. It's now quiet as the sun has set and there's little electricity around. The fishing boats still go out even when it's completely dark and they are almost invisible. I have seen some large container ships to and fro today and am really hoping that they are bringing supplies to Sierra Leone such as protective gear etc. as it is so desperately needed.


A few of our group have left today and am sure there will be others to replace.


I'm beginning to hear stories of the stigma us volunteers to Ebola regions are facing. Children are being teased and isolated even before mothers are deployed. Someone was told not go to certain shops or do things he used to do back in his hometown. Ebola is a terrible disease but so is the ignorance and misinformed fear.  Ebola is easy to catch and very easy to avoid.

I should be contacted each day to give my temperature, but that hasn’t happened yet.


Monday 27.10.2014

Temp 36.9


One of the mental health nurses has sadly died of Ebola near Freetown.

We plan for training. Lots of meetings. Not very exciting, but necessary. We meet with IsraAID.


Tuesday 36.7


This is really what development work is like. Running up and down stairs, organising certificates at the last minute, training materials etc... The printer can't do it, the budget is wrong. There are all sorts of obstacles and it feels so good to be back in this familiar situation.  Trying to organise training overseas is less about the content but more about making sure that the lunches are there, the per diems, the pens, and notebooks. All the things that people expect. As we speak the printers are working late to produce 3 books per participant of notes. PFA and mhGAP. Participants are on their way from all over country for the training.


SKYPE meeting with London at Kings.  Usually I have been in the London office and watching the people on SKYPE in Freetown. But I kept forgetting the microphone was on and being careless with my speech.


Last part of the day today was with the printers . I was driven down to the centre of town to the printing shop. This is where you can get so paranoid. I felt so uncomfortable moving around in this unfamiliar environment and having to touch things around e.g.  the walls, another phone or strangers.


I'm now beginning to think of my journey back, which is only a short while away. I was talking to a colleague just now who was saying that when she leaves Sierra Leone, she would be here 3 months; many of her friends with children have asked her to stay away.  In Geneva I heard WHO has been asked to discourage people from West Africa staying in hotels for fear. There is so much fear and ignorance. The feeling, more or less, is if you have no temp you are ready to go anywhere and no risk.


Wednesday 29.10.2014


This day is a joy for me. I am doing what I love to do and in my natural environment training. I loved the day. I started off with running around for stationary that wasn't ready the day before and racing to the printers for hand outs.


Instead of 50 we have over 60 attend. These were nurses, social workers, and doctors and delighted to have a survivor health worker present.


We start with remembering those who have been lost to this disease and includes recently one of the psychiatric nurses


We cover communication skills, psychological first aid and stress module of mhGAP WHO curriculum. It was a very interactive group. All are so stressed by Ebola and all in the day was prismed through the terror of Ebola.


Some myths that we struggled to clear include that stress can cause you to have a temperature rise. Well-done team!  Good work. Investment in these 60+ people to go out with this knowledge and train others and use in principle. There are so many applications for these basic ways of psychosocial support – burial team, 117 emergency phone line, workers in isolation units, bereaved, the scared, the orphans… It goes on and includes us lot, health workers.


A survivor health worker had gotten over Ebola but he still had family in quarantine and in isolation unit. He spoke about how horrible the experience was so harrowing. Now he is desperate to see his family who are in a quarantined area so he hasn't been able to get permission to get there yet.   It was a privilege having this man speak to us of the stigma he faces, isolation and prejudice.



Thursday 30.10.2014  


Temp this am 32.4 degrees!


(Maybe I shouldn't rely on my thermometer so much!)


Meeting of Psychosocial Gender Child protection Pillar today.  This is basically a meeting of all stakeholders in this area. Lots of people attend doing psychosocial in this country but lots of stories that are horrific. Children whose parents test positive for Ebola are kept with them in an isolation unit and destined to catch the virus for sure. This is anecdotal but is definitely happening.  Lots of missing data...


The Minister of Social Welfare arrives to tell us work together. But in truth I have seen a lot of coordination in a constructive way. Sure there is duplication sometimes but at least we have some way of mapping and seeing it. This is nothing like Haiti.


More meetings:

Meeting in eastern district so we drive across town – all is going on as normal. Markets, shops, traffic. Its only when I go to the hospital, talk to local people and colleagues that we realise how terrible the situation is and we remain a hot spot here of cases. No cases amongst our staff in a few weeks, which is most reassuring. We are all following strict guidelines on infection control. I now know there is a speciality of infectology and lots of epidemiologists and surveillance happening.


Temperature ok but the driver next to me has low-grade fever. So I get out of the car and have just drenched myself in alcohol and put all the clothes in for a wash. This is amazingly enough to protect yourself from this lethal but fragile virus. Detergent, chlorine, soap can really kill this deadly bug.


Friday 31.10.2014


Another hot day in Sierra Leone – hot in weather and hot in terms of new Ebola cases.


And yet frustrating to be caught up in so many meetings.


But we met the mental health coalition. These are the Sierra Leonean mental health players and  it's really important that they lead on the psychosocial strategy and implementation in the country. I was hearing the story of a survivor from a treatment unit. They described the inhumanity of it but there was one health care provider who used their name each day and that really made a difference. The other staff just left food and water nearby and denied them any human contact. PPE – (personal protective equipment) is bad enough but this is just lack of common humanity.  Survivor I met the other day - I now realise he lost his wife and daughter. This disease is so devastating. He wants to visit his family who are ion a quarantine area. They don't believe that it is him on the phone. There are myths going around – that chlorine can cause Ebola. There is such a lot of hysteria in the panic.


I was sitting through another meeting and thought that this is really frustrating  and starting a nurse led clinic is going to be drayed so long . So have started a little informal fundraising to get chairs, desk, fan, basic stuff for a clinic. A quick email and have already got pledges of several hundred pounds.  Humbling and so rewarding as this will really make a difference.


Latest figures 1,510 cases of lethal Ebola in Sierra Leone and double the sickness rate. No sign of any reduction of rates.


Heard a chilling story about ambulances. Drivers wear Personal Protective Equipment. The ambulances are often not washed so I'm guaranteed to get Ebola if take an ambulance.


Today I went with some WHO colleagues down the road on Sunday to a little market. There are no longer tourist visits but the market stalls still sell, or try to, with the diminished trade.  Lots of fish for sale and fruit, as well as usual tourist stuff in Africa. I came back to hotel and showered to clean myself after this.  Temperature was 37.7 on arrival to hotel. But had been walking in the sun so I managed to check again and I was back to 36.5.


It was interesting that at a sensitisation exercise with religious leaders a colleague was telling me how they were angry at the message that God doesn't cause Ebola. They actually felt that the people in quarantine were there as a result of punishment from God.




27/10/2014 10:09:09

Sierra Leone by Peter Hughes


This is a personal blog and does not represent views of any organisation

8.10.2014 - 19.10.2014

Siera Leone
I am a UK based psychiatrist with an interest in global mental health.  I also happen to be Lead for Kings Sierra Leone mental health link when in UK.




I was due to be in Sierra Leone for the link in September 2014.  However Ebola happened and my trip was cancelled as our mental health project had to be shelved while Ebola overtook all.


So, I had put Sierra Leone out of my mind and was in Geneva at a WHO meeting when asked if I would consider a role in Sierra Leone in psychosocial response to Ebola.  I didn't need to be asked twice. I wasn't being brave or foolish. It was going to be a non-clinical role.


I got a little taster the following week of Ebola awareness in Nigeria. The Lagos airport experience is quite something at the best of times but now has an extra level of Ebola screening, with forms and temperature-taking on at least 2 or 3 points through the building.  Then the logistics of health clearance paperwork to get things ready.

There are currently 22 million people in need, due to Ebola...

8.10.2014  I'm waiting for the email to say when I will be out. It is frustrating waiting as just want to get out there and start the work. Aware that many around me are worried about me and as well my return.

Finally Thursday 9.10.2014 I get the email that am ready to go – right in the middle of an academic programme at work.


On Saturday I met someone in London who would have been travelling at the same time to Sierra Leone in September. Her remit is community mobilisation and she seems to have an untapped and really useful approach.


Other projects I am involved with are linked to Kings – for example to distance mentorship support of Kings volunteers by UK based volunteers. We had a very interesting meeting about this and people seem really fired up to do this project. Mentorship is low key, voluntary and Sierra Leone led.


I have to say I can't really bear to watch anything on television or listen on radio to anything about Ebola as it is getting very close to me and it is utterly terrifying.


It is Sunday 12.10.2014 and I am writing this in London city airport. I am en route to Geneva – a town that I stopped over in the past and now my second trip in a month.

Sierra Leone

I have little idea of what I will be doing in Sierra Leone. I am getting messages to stay safe and some people seen convinced I shall never return.  There is no Ebola screening at this time in London city airport and wonder if it will be here by the time I get back.



I have a heavy timetable ahead of me this week with heath checks, counsellor and Ebola protection workshop for 4 hours.


There are issues you don't really think about; the rocketing costs in Sierra Leone and how that might affect me and everyone else. 


I know people criticise WHO easily, but I sat in on an Ebola meeting on Monday and it was impressive. It had a real emergency and urgent air about it, with roughly 30 to 40 people squashed into small room. The walls were covered in screens with maps and charts. The map of Liberia seemed to be covered in large, angry red circles. Sierra Leone much less so. The word from people on the ground in the 3 countries: grim and bleak. An unforgiving virus. There's an apocalyptic feel to the discussions. Yet some hope as well. The regional centre for Ebola is being established in Accra.


I am reminded of my hand-washing training at work. Finally.

Assume a state of relative social and physical isolation from others; no kissing, embracing, handshaking etc... Take temperature frequently and if above 38, stay put and ring for help.


I'm waiting to see the staff counsellor who is now caught in a car crash traffic jam in Geneva. This meeting is compulsory and I'm not sure what it will be like. I am psychiatrist - so I presume I will be highly defensive.


Later that day:  Counsellor was not too bad at all. A simple chat really. The interesting point was whether I knew my exact terms of reference in case I was asked to do something outside of the remit and if could I say No.


Ebola training in classroom that afternoon. This was a lecture on Ebola, its biology, latest info and WHO structures.


Since 19.9.2014 there is a new structure for UN called UNMEER, which is UN Ebola Emergency Response. They have various stages of response with aims of stopping Ebola; treating, ensuring essential services can go on, protection and prevention - one of aims of course, being eradication of Ebola.


One of the participants is going to Liberia and particularly interested in benefits to family, in case of death.   There are currently 22 million people in need, due to Ebola.


Ebola is a relatively fragile virus, which cannot be airborne-spread. It has a spectrum of infectivity for body fluids, with blood not being highest for infectivity. Sweat is a controversial area, but Ebola is probably not spreadable through sweat.  Vomit and diarrhoea are the big carriers and, from what I hear, buckets of it. Dead bodies are the other lethal host - described as an unbelievable viral load in those that die. Some say the virus can still multiply in dead bodies but at the very least, the virus load is incredibly high for a few weeks. Some worry about water contamination from burial. Ebola not strong enough to withstand water, so this is unlikely. In Monrovia now, cremation is mandatory.  That was really shocking, knowing how important burial rituals are to people in Africa.


The only certain risk of infection is when someone has a fever. About 15% have a low-grade fever.  The virus can probably last about 24 hours outside of the body but, in ideal circumstances, maybe a few weeks. It's a lipid-covered virus, making it vulnerable to destruction.  It is surprisingly vulnerable to any disinfectant and soap and water. We had hand washing training again. 40 - 60 seconds. Using hand-rub for 20-30 seconds. Chlorine is also effective in destroying Ebola.  


Lab diagnosis can be 4 hours if testing nearby. Viral load is directly related to fever. Survival depends on pre-existing health. West Africa is prone to pre-existing health problems anyway. Some have called it the “male measles” but occurs in both sexes.


Infection prevention and control (IPC): this is at various levels from national, environmental to PPE (Personal Protective Equipment) and needs special training in the use of PPEs. But generally, hand hygiene is one of the most important means of controlling Ebola. Gloves are so important.


The real risk to people is instinctive; touching of face, eyes and mucous membranes. This is so dangerous after contact with any suspect body fluids. Hands should never be above the waist.


We are in phase 1 – within the first 30 days of establishing treatment centres.


WHO have a lead role in the health side of response as part of this integrated approach. It has roles of coordination, technical and operational.  Tasks are case management, surveillance diagnosis, and social mobilisation amongst others...


There are many horror stories from those who have been to the region; a woman in childbirth haemorrhaging to death as no one will go near her; people dropping down on streets of Monrovia and no one goes near to children who, as they survived are accused of being witches.


Assume a state of relative social and physical isolation from others, no kissing, embracing, handshaking etc.  Take temperature frequently and if goes above 38 stay put and ring for help.


Others in my training were involved with epidemiology and surveillance and logistics.


Hearing from my colleague in Freetown of his series of meetings, which always seems to start with hearing of the deaths of staff. What is extra poignant is the deaths of not only the staff member, but of all their children as well.


A lot of media coverage at present but the challenge will be when it is old news or the news will the western cases of Ebola.


I know people say I am brave to go to Sierra Leone for Ebola. I am not, because of the risk of Ebola which is low to me,  but we are facing a challenge that seems overwhelming. Trying to help with a psychosocial response to the catastrophe of Ebola.



Checked in my 30kgs luggage. Not sure how I got that through to Freetown via Morocco.  I am acutely aware that I now have a cold and am coughing. This will be a problem in such an environment.


Checked in for the flight to Casablanca. You can spot the people going on to Monrovia and Freetown.  They are determined and distinctly casually clothed. Hold on – now I know the MSF T-shirt, bag – the whole visibility works.


I'm now in Casablanca and aware that this may be one of the last times I will get a chance to write.  It's really colourful with all the people en route to all the countries of west Africa in their very elaborate clothes.  I hadn’t seen this since living in Chad. Eating in a restaurant with a smoky atmosphere – nostalgic for the days of smoking indoors.


I've just heard the UK has forbidden direct flights from Sierra Leone to UK. This is a real logistical problem  for UK-based efforts. For me, I arrived recently back from Nigeria via Amsterdam with an Ebola check in Lagos. No fever – ready to go...

Actually, there's very little point in checking at the end of the journey. But self-monitoring for the next few day after is really important. I walked through Heathrow with no check. I arrive back from here through London City airport and suspect there wont be any checks there.  But temperature screening when leaving West Africa is vital!


Day 1 Freetown

Temperature taken at arrival of hotel, arrival at WHO office and am repeatedly washing hands.  Remembering no handshaking and no touch. 1 metre distance to any patient.


Ebola induction. Some horror stories e.g. the religious leader dying and the water used to wash him also being used to wash 40 children with predictable results. It's hard to imagine this is hot spot, as we see on news when in the middle of it.


Day 2 temp 36.8. Ready to go...



This has been a busy day. I went to the main Psychiatric unit and met the head of hospital, psychiatrist and all the staff.  Driving through Freetown looks the same as usual. Busy streets, markets, traffic. You can easily forget Ebola apart from the graphic posters everywhere. I visited the new planned isolation unit for the mentally ill should anyone with mental illness need it.  We know that mentally ill people are a special group in terms of marginalisation, social exclusion and with increased likelihood of picking up bugs and viruses. They need that extra level of protection. The hospital has about 60% drug-induced psychoses - mainly cannabis. There are over 200 beds. The isolation unit is still empty and not used yet. The wards were ok – certainly not the worst I have seen in the world and thankfully with no one chained. The staff is caring and ensure good care in a poorly resourced situation. The medication plans were a bit different to those I am used to, but it's not for me to comment or interfere.


World mental health day was held today -1 week late. It was beautiful. It started with a prayer from a Christian and then al fatiha prayer from a Muslim. Sierra Leone is a great model of religious tolerance.


It bought me back to the same type of situation in Haiti where the staff were present, smiling and yet all had stories of personal loss. They had lost a member of their own in recent days. The staff are close-knit, so this is terrible for them. We had some speeches emphasising their commitment to patient care and to the future tasks ahead. We spoke about the approach ahead of community care; humane, human rights-based care with extra protection for the vulnerable.  


The next part of the afternoon brought Ebola home to me in an anguished pain. A young man comes to meet us. His mother was a health worker who has died. His pregnant wife died and his brother.  I really don’t want to intrude in any way on his private grief but it was a moment that could not be described. 


I haven’t seen people keep social distance and there's less hand washing than should be.


Back to hotel. Temperature 36.8.  OK to go... 

Outside the window I can see the fishermen nearby and people swimming.  People pass to and fro. This really is a beautiful place and an enormous hotel room. I just wish I could get some TV channels that weren’t purely focussed on Ebola. I really can’t bear to hear more about it.

Bedtime. Temperature 36.4


18.10.2014 Saturday 36.2


Started off as a quiet day. Then we got called about an incident in a clinic. When we arrived we found that a man had died on the site who was positive for Ebola. This was scary. The burial team arrived dressed in PPE personal protective equipment.  In white and yellow suits, they were spraying throughout including the places where we had been sitting. Next, a staff counselling session. I won't break confidence about the content but there was understandable terror on the risk from exposure and what to tell my family. What is an issue for people is the stigma or not only being diagnosed with Ebola but also the stigma of working with patients with Ebola. People are asked to leave their accommodation and whole areas are quarantined, We had to leave a via a different exit as contaminated materials blocked the route. 




Good meeting today with an NGO.  This was especially nice for me as I'd worked with them before and already knew some of the people.  It was good to see that we are all thinking in the same direction of travel, and have some good plans in place. Plans are around setting up psychosocial foci throughout the country and using existing human resources.


Everyday we see local fishermen and boats heading out to fish and carry on normal life. Some reassurance of normal life...




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  Dr Peter Hughes, RCPsych Blog Editor

RCPsych Blog Editor, Dr Peter Hughes, is a consultant psychiatrist based at Springfield University Hospital, London. He has an interest in international psychiatry and has been travelling to Africa over the last five years doing short-term assignments in mental health.

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