Last December, more than 40 British medical staff members departed for Bangladesh to tackle an outbreak of diphtheria among the Rohingya refugees.

Among the group was Dr Derek Sloan, a Fife physician and consultant of infectious diseases at the University of St Andrews.

The Saint spoke to Dr Sloan to find out more about the deployment and his experience as a consultant.

While Dr Sloan has travelled abroad with emergency medical teams in the past, he explains that much of his current workload is based in Fife.

“At the University I do a combination of research into the treatment of infectious diseases and some teach-ing. At NHS Fife I’m a clinical doctor, and I see patients in the acute medicine admissions unit and also across the hospital.”

Dr Sloan started specialising in infectious diseases around 2003 and notes that the human element of the field is one of the primary things which sets it apart from other areas of medical expertise.

“It’s an interesting area of medicine because infectious diseases are common, but particularly common in resource-poor parts of the world. They’re often associated with adverse socio-economic circumstances, with people’s occupations and their lifestyles, and so the interaction between the person and the disease itself is usually quite an interesting one. Because they’re so associated with living circumstances, there’s often a political dimension to the management of them,” he explained.

Another element that distinguishes the field of infectious diseases for Dr Sloan is the ability to find remedies.

“A lot of the time infections can be cured, which is a nice thing to be able to do as a doctor because lots of diseases can’t be cured. So being able to completely get rid of the problem sometimes, not always, is a good thing about being an infectious diseases doctor.”

UKEMT

Outside of his work in Fife, Dr Sloan is also part of the UK Emergency Medical Team (UKEMT).

The UKEMT is a community of medical professionals which acts as the front line for the UK’s response to large-scale humanitarian crises over-seas, such as earthquakes or tsunamis.

The team is made up of a diverse range of professionals, all trained to deal with a variety of different issues.

“You need a mixture of doctors and nurses, and what we call allied health professionals, so that’s physiotherapists, ambulance drivers, paramedics, pharmacists, [and] X-ray specialists. A different emergency might require different people.

“If you think of all the [various] types of people who work in a hospital, it’s made up of all of those types of people,” Dr Sloan explained.

Generally speaking, the members of the EMT are quite senior in their job. As a doctor you have to be either a consultant or a senior registrar, and as a nurse you need to have been qualified for a minimum of five years.

The reason why UKEMT asks for quite senior volunteers is because those deployed need to be able to start work as soon as they arrive.

“The idea is that you are there to do the jobs, so you can’t be having training needs when you arrive,” Dr Sloan said.

The mission to Bangladesh was the first deployment of UKEMT after it was certified by the WHO in 2016

The UKEMT is a partnership between UK-Med, which recruits, trains, and prepares its health care workers; the Department for International Development; NGO Handicap International, which specialises in rehabilitation; and the UK Fire and Rescue Service, which provides logistic support, safety, and security.

Previous deployments of the UK-Med have included: a response to Typhoon Haiyan in the Philippines in 2013, a deployment to treat victims of the renewed conflict in Gaza in 2014, a deployment of a team to Sierra Leone in 2014 in response to the Ebola Virus Disease (EVD), and a deployment in 2015 to Nepal to provide support after the earthquake.

Following these deployments of the UK-Med, the mission to Bangladesh in December 2017 was the first deployment of UKEMT after it was certified by the World Health Organisation (WHO) in 2016.

Although this was the first official deployment of the UKEMT, preparations had been under way for several years.

“It’s not an easy thing to do to deploy a medical team like that, so the process of getting the team ready to deploy has actually been going on for a really long time, almost ever since the Ebola outbreak ended in West Africa,” Dr Sloan said.

“It’s a team of people in Manchester, really supported by the Department of International Development in London, that have been working on organising all the logistics to be able to deploy another team. So there have been training exercises and all that kind of stuff that [has] been going on for years,” he added.

Deployment

The deployment in December 2017 saw more than 40 British doctors, nurses, and firefighters from the UKEMT make their way to Cox’s Bazar, Bangladesh, to save thousands of lives at risk from a rapid and deadly outbreak of diphtheria among the Rohingya people living there.

The plight of hundreds of thousands of Rohingya people is said to be the world’s fastest growing refugee crisis. Risking death by sea or on foot, the Rohingya people have fled the destruction of their homes and persecution in the northern Rakhine province of Myanmar (Burma) for neighbouring Bangladesh since August 2017.

The UK’s decision to deploy the UKEMT to deal with the diphtheria crisis among the refugees followed a formal request for assistance from the WHO and the Government of Bangladesh, after more than 2,000 suspected cases and 22 reported deaths from the airborne virus.

Diphtheria is a fast-spreading, extremely deadly infection, and at the time of deployment, there were 160 new cases appearing every day in Cox’s Bazar. Diphtheria is especially dangerous for children as they are particularly vulnerable. The disease can cause extreme difficulty breathing, inflammation of the heart, which can lead to heart failure, problems with the nervous system, and fatal paralysis.

Dr Sloan explained that, because diphtheria is preventable with vaccines, it is a rare condition in the UK. Only about 20 cases of diphtheria have been reported in the UK over the last 20 years, and therefore few members of the team had actually dealt with the disease before this deployment.

At the time of deployment, there were 160 new cases of diphtheria appearing every day in Cox’s Bazar

“Almost no one in our team had seen patients with diphtheria before, so there [were] quite a lot of people trying to learn about the condition, how to recognise the condition, [and] how to treat the condition. That was even amongst quite experienced doctors, nurses, and paramedics, the people on the team, so I suppose that was a bit of a learning curve.”

Even as a consultant of infectious diseases, Dr Sloan himself had very little exposure to the disease before travelling to Bangladesh.

“I’d seen diphtheria before, but even I’d only seen two or three cases of it in my life, so even with people who knew a little bit about it, this was different from what we’d ever experienced before.”

While the team was in Bangladesh, they spent most of their time working in a treatment centre to combat the disease, which, as Dr Sloan points out, is slightly different from what the team is trained to do.

“The deployment was slightly unusual in that the UK Emergency Medical Team was actually set up to be able to deploy and build and run a hospital by itself, and we would be able to do that, that’s what we’re structured to do. But because the specific situation in Bangladesh was that the camp already existed, there was very little space in the camp, and so we worked in three facilities that had already been constructed by an organisation called the International Organisation for Migration.”

Diphtheria

While in the treatment centres, the main task of the UKEMT members was to diagnose and treat diphtheria.

“Patients would come when they had symptoms and we would examine them and decide whether we thought it was diphtheria or not,” Dr Sloan said. “If we thought it was diphtheria we would admit them and we would look after them; we’d keep them in the hospital for two days, give them antibiotics.”

In order to best control the outbreak, Dr Sloan and his colleagues administered an antitoxin to the patients who displayed the most acute symptoms of diphtheria.

“One of the ways in which diphtheria makes you sick is that the bacteria makes a poison, a toxin, that releases into your tissues, and so one of the treatments for the people who are the most sick, who are at risk of dying, is they have to be given an infusion of antitoxin, which is a sort of antidote to the poison produced by the bacteria.”

The antitoxin for diphtheria is made in horses, not humans, so the human body is not familiar to it and allergic-type reactions are a risk when administering such a treatment. This made its application one of the most difficult parts of the diphtheria treatment for Dr Sloan and his colleagues.

“You have to give it very, very slowly and you have to give it under very, very close monitoring. And they can be dangerous if it’s not administered by very expert people,” he said. “

Quite a lot of the patients in the diphtheria outbreak were very small children so the majority of people were under 15, and a substantial proportion of the patients were under five.

“They had started to develop allergic reactions, which was quite frightening and you obviously didn’t want a little child to die because of medicine that you’d given to them. So a lot of the time our work was to make sure the antitoxin was given safely,” Dr Sloan added.

In addition to the difficulties of safely administering the antitoxin, the UKEMT was met with several other challenges during the deployment.

Many of the challenges that the team faced stemmed from the unfamiliar task of working in a refugee camp. The camp itself is situated on the border between Bangladesh and Myanmar, and, as Dr Sloan said, “it was a chaotic place for people to live, so trying to set up any medical facility in the middle of that was not particularly easy.”

The nature of the sudden arrival of the Rohingya people in Bangladesh meant that Dr Sloan and his colleagues were confronted with ongoing political discussions and uncertainty while working at the camp.

The majority of [patients in the diphtheria outbreak] were under 15, and a substantial proportion of the patients were under five

“They’d just arrived in Bangladesh, but the Bangladesh government wasn’t expecting to have all these people on the border so they had to work out what to do with them. There was a lot of ongoing political discussion about whether or not the Rohingya people would go back to Myanmar or whether they’d stay in Bangladesh, or whether they’d go somewhere else, who was responsible for them. So trying to organise medical services in the middle of all of that uncertainty was not easy.”

Working in a refugee camp also created logistical challenges for Dr Sloan and the rest of the UKEMT.

It was deemed dangerous to stay in the camp overnight, so the team had to take an hour bus ride most morning and evenings to get in and out of the camp, sometimes sleeping in tents at the back of the camp over-night to give treatment to the patients.

In addition to this, the unreliability of the energy sources at the camp posed problems in terms of refrigerating the antitoxin.

“Making sure that we had a constant supply of electricity to keep the fridge running was a challenge. There’s a shortage of diphtheria antitoxin in the world so there were only 6,000 vials in the world when we were treating patients in Bangladesh. And at the same time as the diphtheria outbreak in Bangaldesh, there was one in Yemen, and there were smaller outbreaks in Indonesia and Haiti and Venezuela. So there was quite a lot of demand for this antitoxin and we had quite a lot of it.

“Therefore we had to really be careful that nothing went wrong with the electricity, that we lost a big batch of antitoxin and that might have been a big proportion of the worldwide supply.”

As a result, this aspect required significant monitoring from the volunteers.

“You had to make sure that the generator came on if the power in the camp went off, make sure that it stayed on and that the temperature of the fridge was correct, and that takes a lot of time. And it’s the kind of thing that under our usual circumstances we would take for granted, but you couldn’t take it for granted. You had to pay attention to it every minute of day and night,” Dr Sloan said.

The EMT was also confronted with treating a large proportion of children in the camp, some of whom were unaccompanied.

“There were a million people living in the camp more or less, and half of them were under 15, and 20 per cent of the people in the camp were under five. So there were lots of unaccompanied children, there were lots of women and children by themselves, and that made it hard because quite often you were looking after children in the clinic and there was no parents there.”

The number of cases is gradually reducing, but it’s not completely gone yet

On top of this, the language barrier meant that it was difficult to explain the treatment to many of the patients.

Most of the time, Dr Sloan and his team members were “relying on Bangladesh interpreters who could only partially understand what they were saying,” which meant “trying to explain complicated treatments to people was not that easy,” he said.

In spite of the challenges that they faced, Dr Sloan describes this first deployment of the UKEMT as successful, particularly due to their success in relieving pressure in a mother-and-child health centre run by Médecins Sans Frontières (MSF).

Before the UKEMT arrived, the centre was overwhelmed by diphtheria patients. However, “within a couple of weeks of us arriving they more or less got back to normal,” Dr Sloan said.

Although the EMT has now returned to the UK, some organisations remain deployed to deal with the crisis.

“The number of cases is gradually reducing, but it’s not completely gone yet,” Dr Sloan said.

Diphtheria is preventable with vaccines, but as Dr Sloan explained to The Saint, there are many logistical challenges involved in vaccinating large groups of people.

“You have to give every person three doses of the vaccine, and the doses have to be given a month apart, so you have to be able to go out again and again, vaccinating and re-vaccinating people. You have to be able to keep track of who you vaccinated the first time, so you know whether you’re giving them the first, second or their third dose of the vaccine.

“Some people have never been vaccinated before and they don’t know what a vaccine is, they don’t want to have an injection, they don’t understand what it’s for, and so that process can take quite a long time,” he said.

Looking ahead

As with any other humanitarian crisis, the UKEMT were faced with the difficult decision of when to deploy to Bangladesh, and when to leave.

Dr Sloan explained that this is a common dilemma in his field of work. “Often, infection outbreaks occur in places where the health infrastructure is not very strong anyway.”

Dr Sloan maintains that, as an emergency medic, “your job’s not to go and set up a health service, so you always have to decide when to leave. You have to set up quite clear parameters on why you’re going and what you’re going to do and when you’re going to leave. And there are other partners trying to develop health-care care provision in a more sustainable way, but that is difficult in a refugee camp because officially, the camp of Kutupalong is not a permanent settlement. Officially those people will not be there forever.

“At the moment there is no clear explanation of where they’re supposed to go, and there is a chance that people will be living there for twenty, thirty years, and whose going to be responsible for their healthcare is a very complicated question,” he added.

As the UKEMT is comprised of people who work in the NHS, the volunteers are not able to provide normal health services abroad after their initial deployment.

“It’s not possible that people can just leave their jobs for months and months and months – you only get released for four to six weeks, and then you have to go back to your normal job.

“So the Emergency Medical Team is not set up as a sort of replacement health service; it’s set up as a kind of sudden deployment resource to manage a specific problem,” Dr Sloan said.

When asked about the long-term goals for the health of the people, Dr Sloan suggested there are likely to be ongoing problems within the camp, even if diphtheria is eradicated.

[This is] a real example of what happens when you don’t vaccinate people

“Ultimately you would hope that diphtheria will be brought under control by a combination of treatment and vaccination, but the health problems of the people in the camp will persist there for much, much longer. And so even if diphtheria is brought under control, then there is an obvious risk of other outbreaks of other infectious diseases, and that’s a much, much more difficult long-term problem to control.”

When speaking to The Saint, Dr Sloan expressed his passion for the work the UKEMT does, explaining his belief that it is a vital part of the UK’s international responsibility.

“I think it’s important to know why the Emergency Medical Team exists because it’s likely that they’ll be deployed again, and it’s a component of the UK’s commitment to international development. And I think it’s part of our international responsibility to support other people when they encounter unmanageable problems like this.”

He also explained that the diphtheria outbreak is a “real example of what happens when you don’t vaccinate people.”

“There’s quite a lot of publicity given to the anti-vaccination campaign in the UK, and I think sometimes it’s easy to be sympathetic towards that and to say, ‘Yeah, people shouldn’t have to vaccinate their kids if they don’t want to,’ and while that might be true, I think it’s easy to become complacent about vaccine-preventable diseases when you live in a country where they never exist.”

For Dr Sloan, the experience of delivering healthcare to children suffering diphtheria made him rethink pro-vaccination advice given.

“I think when you have to go and deliver healthcare to small children who are dying of diseases that could have been prevented by vaccination, it does sometimes make you wonder whether people should take it on board a little bit more,” he said.

“I think it’s also important to remember the ongoing problems that the Rohingya people are having because, whilst we are home now and the diphtheria outbreak is at least smaller than it was, and will hopefully eventually be completely controlled, it’s very unclear as to what’s going to happen to those people, many of whom are very young and vulnerable, and it’s difficult to know where they’re going to be able to live,” Dr Sloan said regarding the uncertain future of Rohingya people.

“It’s important that the attention of the world media [is retained] on them and their problem because they’re quite easily and quite regularly forgotten.”

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