Military healthcare professionals' experiences of ethical challenges whilst on Ebola humanitarian deployment (Sierra Leone)

Ebola virus virion

This project will explore the ethical challenges that faced UK Military Medical personnel who were deployed to the recent Ebola epidemic. It will also provide training materials that will help these and civilian humanitarian healthcare workers to anticipate and meet ethical challenges more effectively in the future.

Ebola is a serious, infectious and life-threatening disease. Parts of West Africa have since 2014 been in the grip of the first Ebola epidemic. The epidemic quickly overwhelmed the capacity of local services. Thousands of people became seriously ill, and many died. The loss of local heathcare workers to Ebola made dealing with the crisis even more difficult for affected communities. In August 2014 the World Health Organisation declared the epidemic to be an international public health emergency. It was felt that if the situation was not brought quickly under control, a pandemic (affecting countries beyond Africa) would result.

The UK Military deployed its own healthcare professionals in Sierra Leone, one of the most seriously affected countries. This deployment formed part of the UK government response to the crisis.

Our research is funded by the ESRC (Ref ES/M011763/1), under its Urgency Grants Mechanism pilot, and the Royal Centre for Defence Medicine.

Past event:

Disaster Bioethics

2nd Disaster Bioethics Summer School, 7th - 11th September 2015
University of Birmingham

This event is targeted at those who respond to humanitarian emergencies and disasters. It will also be useful for academics working in the broad area of humanitarian crisis, particularly in ethics.

The aim of the week is to give participants sufficient skills, knowledge and confidence to work up their own case study material, which could be used to provide some basic ethics training or preparation for humanitarian healthcare workers in one area of the participant’s interest or experience.

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Who are we?...

What are we trying to achieve?...

The primary aim is to explore the experiences of UK Defence Medical Services (DMS) personnel in relation to ethical decision-making and challenges whilst deployed on Operation Gritrock. This will enable us improve ethical training and preparedness in relation to ethical decision-making for outgoing military and civilian personnel. 

The project’s secondary aim is to improve understanding of the ethical complexities and issues faced by DMS personnel deployed on purely humanitarian missions, and to compare and contrast their experiences with those of civilian humanitarian healthcare workers.

We will be exploring the following questions:

1. What were the characteristics of the ethical challenges faced by military healthcare professionals who deployed early in the UK response to the Ebola crisis in Sierra Leone (Operation Gritrock)?

2. What can be learned to enhance future ethics training from how these ethical challenges were experienced and responded to? What preparations or resources were or would have been helpful?

3. What were the similarities and differences between the experiences of our participants and known experiences of other civilian, expatriate humanitarian healthcare workers?

4. To what extent did participants feel that their ethical skills and values were affirmed, enhanced or eroded by their experiences?

What are we going to do?...

We will be interviewing military healthcare workers who deployed to Sierra Leone. We will be asking them about their experiences, concentrating on the ethical challenges they faced, how well prepared they felt to meet these, what could have been done better to prepare them and what impact these challenges have had on their professional values subsequently. 

Download our information sheet for participants

We aim to capture the experiences of up to 25 doctors, nurses and allied healthcare professionals. 

We will also be reviewing existing ethics training materials ahead of generating training materials for use by military personnel. 

We will also be working with researchers connected with the Disaster Bioethics COST action.

Project news...

UK Military Deployment to Sierra Leone

July is the fifth month of the Ebola Project.  Recruitment continues until the end of July.  Individuals from a variety of groups who deployed with the military field hospital have agreed to take part; these include doctors, nurses, biomedical scientists, Personal Protective Equipment monitors and Combat Medical Technicians.
The deployment of UK military medical personnel to Sierra Leone is drawing to a close as the outbreak is being brought under control and transmission is falling in Sierra Leone1. The World Health Organisation had reported more than 27,500 cases and 11,200 deaths globally by 1 July 2015. To date (16 Jul 15) Sierra Leone has reported 13209 total Cases (suspected, probable, and confirmed) 8688 laboratory-confirmed cases and 3947 total deaths2. 4 July 15 saw many medical personnel return leaving approximately 150 personnel in the country to provide logistic support.

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Ethics training materials taster

June is the fourth month of the Ebola Project; the UK armed forces that were initially deployed to Sierra Leone as part of Operation Gritrock have been returning to work from post-deployment leave since March. To date 15 personnel from tranches 1 and 2 have agreed to be interviewed in order to help us understand the nature of the ethical challenges that they faced in Sierra Leone as healthcare workers in the Armed Forces.

These invaluable firsthand accounts will allow us to develop training materials that can be used better to prepare healthcare workers who respond to future humanitarian crises involving deadly pandemics. Patients’ ‘in extremus’ suffering from Ebola and the highly infectious nature of the virus accentuate even the most common ethical dilemmas.  On top of this, serving members of the armed forces had to contend with their dual obligation as healthcare professionals/military coupled with the context of Sierra Leone, with its extreme heat and already limited infrastructure damaged by the outbreak. The pressure and challenges upon individual healthcare workers were considerable.

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Respondent Fatigue & Research Co-Operation

We are now halfway through the third month of our project, which explores the ethical challengesfaced by British military personnel who deployed to Sierra Leone to deal with the Ebola crisis. So farwe have conducted thirteen interviews, and the initial analysis of the transcripts is under way. Basedon the data collected so far, and working with members of the COST Action Disaster Bioethics, weare making good progress with producing training materials. Heather has also contributed to thepre-deployment ethics training for Tranche 4 and observed part of the simulation field hospital atthe Army Medical Services Training Centre near York, which contains a replica of the EbolaTreatment unit in Sierra Leone. Some striking themes are arising from these preliminary data, andthese will form the main findings of the study. However, they are not the only thing that the teamhas learnt so far from the project. We have encountered our own ethical challenges in doing theproject. Challenges like these will be familiar to anyone undertaking formal research, and fall intothe area of “research ethics”.

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Should we admire people for ‘just doing their job’? 

When pestilence prevails, it is their duty to face danger and continue their labours for the alleviation of suffering, even at jeopardy of their own lives” (American Medical Association 1847) 

Less than a month into our project we learned that one of the deployed medical staff had contracted Ebola and was, with two colleagues, being flown back to the UK for treatment. Thankfully the patient, Anna Cross (a reservist and intensive care nurse), made a full recovery after being treated with an experimental drug

The announcement that one of the team had been infected was a sobering reminder of the risks that have been taken by the healthcare workers who have responded to the Ebola crisis. Early on in the outbreak, the WHO reported that healthcare workers were disproportionately affected compared to other disasters and emergencies. As one of our early informants put it “Ebola feeds on the milk of human kindness”. The people most likely to be infected are those who nurse the sick – be these family members or professionals. Indeed, ensuring care for the carers (local as well as international) is a key driver in Operation Gritrock, which established dedicated beds for Ebola-affected healthcare workers. These were the beds being staffed by the medical military, and therefore presumably by Anna Cross.

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Col Jeremy Henning, currently deployed on Operation Gritrock and Chair of the Advisory Group, for this project posted our first blog: 

6 months ago Ebola was a distant disease, and we were re-posturing the military into a contingency role after years in Afghanistan, looking after trauma patients. Times change quickly and I now find myself, once again in the front line (this time on a ship) involved in a new fight, this time against an illness that threatens the world. 

In many ways this is a unique deployment for the military. We have got used to dealing on a multi-agency basis to re-build communities, but have not had such a close association with medical charities before – indeed this is possibly the first time they have directly asked for our help. On top of that, this is predominately a public health deployment, rather than the peace-keeping or combat roles we have had before. 

All of this brings new challenges, very few of which we had actively prepared for. However, this is proving to be a successful mission, and we can see similar being mobilised in the future. It is therefore vital we capture the ethical issues and challenges that our personnel faced so we can not only help them, but also inform any future deployments.

Additional funding is being generously supplied by the British Red Cross for us to host a Defence Medical Services Ethics Symposium

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