6.4.2015

I am back with my family in Denver after an unforgettable 6 weeks.  My departure from Freetown was marked with a complex array of emotions – sad to leave so much work and many good friends behind, eager to be reunited with family.  I climbed the steps into the jumbo jet at Lumley airport without the expected sense of relief or joy.  I numbly moved through the transition from the heat, brilliance and dirt of Sierra Leone to the air conditioned, pastel-toned sterility of the West.

Back in the United States, I had dreams of Sierra Leone almost every night for the first month.  During the first 21 days home, I was visited daily by a public health nurse to check my temperature. Thankfully, I remained afebrile, and therefore managed to avoid the unwanted media attention that would have accompanied a trip to the hospital for an Ebola rule-out.

It has now been over a month since my departure from Freetown, and the frequency of dreams is steadily decreasing. 

But the memories are still there, clear and vivid, and at odd times they flash unbidden before my mind's eye. Picking up a weak patient to transfer from a stretcher to a rickety cot, her hand tugging at my Tyvek suit.  Holding a bottle of oral rehydration fluid to the cracked lips of a patient too weak to feed himself.  Grooving to the rhythmic, tinny Salone music blaring from cellphone speakers with other clinical staff in the green zone of the Ebola holding unit.  Walking through the dark hallway of the unit, stepping in chlorinated water and watching rats slink away.  The joy and relief etched on the face of an Ebola survivor coming back to the unit to receive his Survivor certificate.

But these memories tell only half of the story about my time in Sierra Leone.  Each day, I was surrounded by some of the most inspirational people I have ever met – both expatriate and Sierra Leonese.  Courageous, compassionate, and capable individuals who chose to work in a very challenging healthcare setting in one of the world’s poorest countries.  Most awe-inspiring were those people who weren't particularly trained for the positions that they willingly stepped into.  I had background training in medicine, infectious disease and public health – it was no stretch to volunteer to work in an outbreak of a viral hemorrhagic disease.  But in this epidemic there were many untrained individuals who saw a critical need and stepped up to the job, in many occasions crafting the solution with true ingenuity and perseverance in the face of a multitude of obstacles.

If there is one emotion that has been constant over this past month of transition, it is gratitude.  I am profoundly grateful to have had the opportunity to volunteer with King’s Sierra Leone Partnership.  Working with this group, I not only had a front row seat to witness and share in the response to this historic Ebola outbreak, but I also had the privilege of working alongside local and international healthcare workers in the trenches of a Sierra Leonese public hospital.  Had I volunteered with any number of NGOs who were in Sierra Leone expressly for Ebola relief efforts, I would have missed out on seeing patients in general healthcare settings and would have had a much more limited scope of understanding about the true issues which facilitated the deadly dissemination of Ebola in West Africa.

Today the epidemic is still far from over, although in Sierra Leone at least, the numbers are declining.  But last week there were 25 new cases of Ebola in the country, only two-thirds from registered contacts, indicating the virus continues to spread in the community without epidemiologic control.  In Guinea, cases are on the up-swing. Unsafe burials are reported in these countries every week.

However, Ebola is not the real threat anymore, and it hasn't been for many months.  The epidemic has shed light on the determinants of the much larger public health crisis: a broken healthcare system that does not - cannot - vaccinate susceptible children, provide consistent quality prenatal care, offer free and accessible care to the chronic infectious diseases HIV and TB, provide public potable water and garbage disposal, and ensure rapid access to good-value preventative healthcare as well as to medical and surgical treatment.  The needed human resources, coordination, money, and political willpower that are needed for an effective healthcare system are still largely lacking.

The public health challenges here at home are very small in comparison.  I tell myself that by continuing my work and training in this country of abundant resources, I will be able to offer better medical services to resource-limited settings in the future.  

But if there’s one thing I learned in Sierra Leone, it's that it isn't the best-trained or the best-educated who make the biggest impact.  It is the willing. 

I hope to have the will to return.

Day 43

28.02.2015

The majority of patients in the Ebola holding unit at Connaught hospital now thankfully do not have Ebola.  Any number of other conditions can cause the symptoms of fever, nausea, vomiting, diarrhea, myalgias, headache, fatigue that fit the Ebola case definition.  Our team clinically diagnosed many other conditions – tuberculosis, malaria, tetanus, diabetes ulcers, typhoid, malignancy, meningitis, HIV.  ‘Clinical diagnosis’ is the key phrase, given that the only laboratory testing done on the patients during their typical 24 – 48 hour stay in the holding unit is a blood test for Ebola Zaire Virus and malaria.  Tragically, patients in the holding unit sometimes die of a treatable condition while awaiting their negative Ebola PCR result.

The official reported prevalence of HIV in Sierra Leone is remarkably low compared to many other areas in sub-Saharan Africa – only 1.5% general prevalence, with a slightly higher prevalence of 4% in the capital city, Freetown.  Seeing patients in the general Connaught Hospital wards, where HIV prevalence is more like 50%, has made many of us clinicians suspicious of those low reported numbers.  After several weeks of seeing patients in the Ebola holding unit with AIDS defining illnesses such as advanced Kaposi’s Sarcoma and severe esophageal candidiasis, I began to wonder if we were missing an opportunity to diagnose HIV in our Ebola holding unit patients.  I floated the idea by the King’s leadership team, who enthusiastically supported the idea.   The idea gathered serious momentum after a short, productive meeting with the young and energetic Dr. Zikan Koroma, HIV director at Connaught Hospital, and the HIV counseling and testing national coordinator, Mariama Conteh. I soon developed a deep respect and regard for these two HIV champions.

The time was ripe for such a program.  With fewer Ebola cases in the unit, there is less risk to staff by adding on a lab test that could expose them to a patient’s blood. Clinical efforts are now transitioning from crisis control to system improvement.  Also, new and intriguing information is emerging that patients with Ebola and HIV coinfection might have a different clinical course of Ebola disease, so knowing the HIV status of patients in the Ebola holding unit would have important clinical and public health implications.

So instead of managing loads of patients with Ebola (I had personal contact with only one confirmed case on my Monday call shift), I ran training classes for rapid bedside diagnosis of HIV.  The concept was simple: routine, rapid, opt-out HIV screening would be performed by local nursing staff whenever a patient was admitted to the Ebola holding unit.  The nurse performing the test would obtain informed consent and provide abbreviated pre-test and post-test counseling.  Positive patients would be linked directly to HIV care upon discharge; ambulatory patients would be walked directly from the Ebola decontamination area to the on-site Connaught HIV clinic; patients needing additional inpatient care would be seen the next day on the general ward by the HIV director, Dr. Zikan Koroma. 

Although HIV medications and treatment is free in Sierra Leone, the majority of patients who have been diagnosed with HIV are “defaulters”, the local word used for patients not on treatment.  This is a loaded term, directly placing blame and fault on the patient.  In reality, the reason why a patient “defaults” on her/his HIV medication is multifactorial.  Patient privacy is a loose term here.  Patients coming to the HIV clinic at Connaught Hospital sit together on a bench under an awning; a nurse comes to the door and calls out a patient’s name.  A typical visit to the clinic consists only of a nurse dolling out 30 days of medication.  Transportation to/from HIV clinics can be expensive and difficult.  And although HIV medication is free, many other aspects of care are not.  For example, chest Xrays are not free, despite the fact that about 30% of patients with tuberculosis are co-infected with HIV.  And stigma against HIV-infected persons is rife.

 

'Pharmacy' at the HIV clinic at Connaught Hospital.  Paper records only, no electronic medical records here.

Antiretrovirals available to treat HIV in Sierra Leone.

Nonetheless, many people with HIV in Sierra Leone find a way to overcome these obstacles and get to clinic and take their medications.  Knowledge is power; I am firmly convinced.  We decided the benefits of giving a patient the diagnosis of HIV outweighed the potential harms.

The training was an enormous success.  The unit nursing staff are extremely eager to learn.  Each training session was 4 hours in duration and consisted of a short introductory lecture on HIV/AIDS basics and a lecture on the concepts, strategies, and talking points of informed consent, pre-test and post-test counseling.  Laboratory staff from the HIV clinic came with rapid diagnostic HIV kits and each nurse performed the testing on positive and negative blood samples.  The nurses took notes during the lectures and requested more information about HIV.  Each nurse proudly took home an official, laminated Certificate of Completion of Training in HIV Testing and Counseling in Emergency Settings at Connaught Hospital.

The first day of HIV testing in the unit diagnosed 2 of 5 patients with HIV.  Each of the HIV-infected patients was successfully linked to care at the HIV clinic on discharge.

Ebola holding unit nurses learning how to perform HIV rapid diagnostic testing.

The rapid HIV diagnostic kits that are used to screen for HIV in Sierra Leone; these kits each require a drop of patient's blood, obtained by fingerprick, and can be done at bedside.  Results are obtained in 10-20 minutes.

Day 34

19.2.2015

Safe burial procedures are crucial to stopping the Ebola epidemic. Corpses are sealed in body bags by workers in full personal protective equipment (PPE) and buried in secure graves. The current official policy from the Sierra Leone Ministry of Health is that every corpse, regardless of cause of death, should be given a safe “medical” burial. Here, the interests of public health, guarding the public against possible Ebola transmission from infected corpses, often collides with that of mourning friends and family, who typically desire a traditional burial in the family plot.

Connaught Hospital, the tertiary referral health center where I’ve been volunteering in Freetown, is positioned next door to the Connaught Mortuary.  I had heard recent rumors that several bodies had been taken out of the Connaught Mortuary by family members to be buried.  It was unclear whether this was being done with the mortuary’s permission or knowledge. I decided to investigate. 

Through a contact who worked with the non-governmental organization Concern, the group responsible for overseeing burials in the greater Freetown area, I linked up with the burial team that was scheduled to come to the Connaught Ebola Holding Unit on Thursday, my day off.  We had two corpses in the unit’s morgue that morning.  The burial team donned full PPE and brought out the two bodies, placing them in the back of an open pick-up truck.  They then decontaminated, put their used PPE in garbage bags, tossed the open bags on top of the bodies and drove around the block to the Connaught Mortuary to see if there were any bodies there to pick up. I followed the truck in a separate car. I couldn’t help but notice that the garbage bags of used PPE were jostling precariously on the rough roads.  Pedestrians weaved in and out of the slow moving traffic, oblivious to the nature of the unsecured cargo.

Following the burial team, in heavy traffic with pedestrians brushing against the vehicles.  Two bodies in body bags lie underneath the open yellow bag of used PPE in the back of the open pick-up truck.

At the mortuary, I introduced myself to the manager, explaining that I was interested to learn more about the burial process during the Ebola outbreak.  I was graciously offered a chair in his cramped office. That’s when things got a bit bizarre.  The manager was in conversation with family representatives of several people who had just died in a motor vehicle accident. The families were petitioning for the bodies to be released for a private funeral.  During the discussion, a woman walked into the office to decant some formaldehyde from a large container in the back of the room.  Possibly seeing my puzzlement, the mortuary director explained it was for ‘body preservation’ happening in the next room.  Odd, given current policy dictates that all bodies be buried immediately. The conversation between the mortuary manager and the family representative dragged on.  Ultimately the family was told that they would need to go the next day to the command center to obtain the results from the oral swab sample for Ebola.  If the result was negative, they would have the option of bringing an official negative Ebola death certificate back to the mortuary in order to collect the body. The unspoken, but clear, implication was that this service would require a hefty fee. 

From this brief exchange, it was made very clear that not all bodies in Freetown are being given safe ‘Ebola burials’.  One might argue that this policy is not necessary – people continue to die from many causes, not just Ebola.  However, it is impossible to know what most people die of – the oral swabs to detect Ebola in corpses are notoriously insensitive and autopsies are strictly forbidden.  The potential public health consequences of a traditional funeral of a person infected with Ebola are enormous: One funeral where traditional burial practices are performed can spread the virus to hundreds.  Each week, the Ebola Situation Report by the World Health Organization reports tens of known unsafe burials in Sierra Leone, a number that is almost certainly a vast underestimate.

The burial team picked up one more body at the mortuary, and then we got back in the trucks for the short drive to cemetery. 

King Tom cemetery is a very old graveyard located in the heart of Freetown, which borders the city dump.  When the Ebola epidemic hit, city officials offered a small area in the cemetery for the Safe Burials.  Soon, the plot was full.  The rational next step was to make more space by plowing into the city dump. 

When we arrived that afternoon an enormous Caterpillar excavator was moving soil to carve out more usable land in the western corner of the cemetery. About 10 bodies in white body bags were already lined up by ready graves, awaiting burial.  The team that I had been following drove down into the area of the open graves. The team again donned full PPE and unloaded the bodies, placing each one by a single grave. 

King Tom cemetery, pushing up against the the rubbish of the city dump.

A small crowd of onlookers had gathered at the mound at the end of the road. I recognized the brother-in-law of one of our patients that had died the evening before, when I was on call.  The oral swab had come back negative for Ebola, which was small comfort to the family. I could hear their wails of grief. 

Each body bag was placed into a single grave that had been draped with a clean white sheet.  The burial team pulled the sheet over the body, placed a number of short sticks in an orderly fashion over it and then began the physical labor of shoveling in the earth.  An imam standing with the family raised his hands, chanting a melodic prayer.

Just beyond the fresh graves, the rubbish heaps of King Tom city dump are visible, pushing against the flimsy barrier between cemetery and landfill.  On this side of the fence, separated by mere inches, the small mounds that mark full graves stretch for hundreds of meters in all directions.

Freshly dug graves, soon to be filled, in King Tom cemetery, Freetown, Sierra Leone

 

Day 26

11.02.2015

Sneaky little virus, this Ebola.  Just when I was starting to get a bit cocky about my clinical acumen in Ebola Virus Disease, an atypical case reminds me that this virus deserves respect.

We actually hadn’t had a case of Ebola in the holding unit in over a week.  I was beginning to wonder if I shouldn’t ask to go home early – my daughter had just taken her first independent steps, and I was missing my husband terribly. 

Walking about the city, I could sense that people were beginning to relax – markets and restaurants were busier, friends could be seen casually touching in the street, boys were back playing soccer on the beach.  One local man informed me proudly that his neighborhood had not had a positive case in 41 days.  Another person at a local restaurant told me confidently that he predicted Sierra Leone would be Ebola-free in another four weeks. 

I was starting to relax, too, and in the worst possible place – the Ebola holding unit.  On Sunday afternoon, we had only 4 patients, none of whom had Ebola in my mind.  I rounded on the patients, refilling bottles of oral rehydration fluids, distributing food, providing analgesics for pain. 

I spent many minutes at the bed of one young female patient.  One day before, she had actually passed through the screening process at the hospital gate; her presenting symptoms had been cough and vaginal discharge.  Her symptoms didn’t fit the standard case definition of Ebola Virus Disease and she denied all risky contacts (contact with anyone sick, travel to an area of high transmission, funeral attendance, contact with sick bats or primates). She was directed to the general waiting area to be evaluated for admission to the regular hospital wards. But as she waited, she developed a slight fever to 38.0 and so was re-directed to the Ebola triage tent.

When I saw her, the day after admission, she was still febrile and was also weak and confused.  A brief exam revealed bedsheets and clothes soaked in urine and mucopurulent discharge.  She didn’t have the classic Ebola symptoms of hiccups, epigastric or right upper quadrant pain, conjunctivitis, vomiting, diarrhea or bleeding.  Instead, her primary complaint was left flank pain. Highest on my differential was pelvic inflammatory disease, tubo-ovarian abscess, or urosepsis with perinephric abscess.  I asked about her family; three children, the youngest only 7 months.  We stripped the bedsheets and bathed her with mild chlorinated water, and encouraged her to drink more fluids.  She had been receiving ceftriaxone as part of the standard treatment package.  Limited in my antimicrobial options, I added metronidazole for additional anaerobic coverage.

The next day, her blood test came back positive for Ebola.  I was shocked.

I wonder now if she could have been actively miscarrying.  Pregnant women infected with Ebola very often do.

**********

I hadn’t had any breaches of my personal protective equipment (PPE) and had dutifully completed all tedious steps of the thorough decontamination process upon leaving the unit.  But on reflection of my actions in the unit, I knew that I had been mentally lax.  I had not limited my time and contact at that patient’s bed to the minimum necessary. 

There is a tension between personal safety and clinical compassion in the unit.  By nature and by habit, I frequently touch patients to convey comfort and sympathy.  A pat on the shoulder, a quick squeeze of the hand can be enormously effective in developing a therapeutic doctor-patient relationship.  But casual contact is forbidden in an Ebola epidemic.  ‘Nor Touch Am’ is splashed in huge letters on billboards across the country.  ‘ABC = Avoid Body Contact’ is the new mantra.  Even in the unit when wearing full PPE, minimum physical contact with patients is the rule.

I make a firm resolution to redouble my mental guard, both inside and outside the unit.

The next day, two additional patients test positive for Ebola at our holding unit.  Since then, we've diagnosed one to four new cases of Ebola in the unit every day this week. This epidemic is not over.   

I stifle my homesickness and renew my commitment to stay in Freetown for the full 6 weeks as originally planned. 

Day 17

03.02.2015

When Ebola cases first showed up in Sierra Leone, it was late May 2014.  Initially, cases presented only in a small part of the country, near an eastern township called Kenema.  By early July, Connaught Hospital had its first case – a businessman who had had been visiting family in Kenema.  Since his return to Freetown, he had been sleeping in close quarters with several other people, despite mounting fever and gastrointestinal symptoms.  One of his housemates brought him to Connaught Hospital for evaluation.

At that time, the only laboratory in the country to run Ebola PCR testing was in Kenema, a 5 hour drive from Freetown on a bumpy road.  King’s Sierra Leone Partnership staff obtained a patient’s blood sample, packaged it securely, and arranged for a courier to deliver the sample to the Kenema lab by taxi.  Two days later, the Kenema lab had still not received the sample.  The courier was tracked down, and ultimately confessed that to save some money he had opted against taking a taxi and instead had taken a boda-boda (popular form of public transportation usually in the form of a crowded mini-bus) – and had lost the blood sample somehow on the way. 

Another blood sample was drawn and sent to Kenema by another courier.  At the time, it took on average over 5 days to get results back on an Ebola PCR blood test.  The patient had died by the time the positive result was reported.  One of his housemates had also fallen ill.

Early in the epidemic, several esteemed Sierra Leonese doctors, including Dr. Kahn, head of the Lassa Fever clinic and national expert on viral hemorrhagic fever, had died.  Fearing for their lives, doctors across Sierra Leone went on strike.   

King's staff scrambled to rapidly expand their capacity to accommodate the flood of Ebola cases. The two bed isolation unit at Connaught Hospital expanded to a 16 bed unit, sometimes with as many as 20 patients.  Patient mortality was over 60%.  It still took many days to get lab results back, and when a result was positive (the vast majority), almost invariably there were no beds available in the few operational Ebola Treatment Units.  As a result, the positive cases were not isolated from the suspect cases in the holding unit, increasing risk of transmission within the unit.   

With no open beds in the Connaught Hospital holding unit, patients with Ebola were often left outside the hospital gate in the triage tent, sometimes waiting for days.  Patients often opted to return to their homes rather than wait in the tent's oppressive heat with other sick and dying patients.  King’s volunteers informally referred to the triage tent as the Tent of Horror.

It would have been easy to get mired down in the weeds of patient care given the huge and pressing needs at the small isolation unit in Connaught Hospital.  But the real issue was the public health disaster occurring at the regional level. Only two ambulances were functioning in the entire country.  Traditional funeral practices with high risk of Ebola transmission were still being performed. Ebola cases were not being isolated quickly.   People with known Ebola exposures were not being quarantined. Dead bodies were not being buried safely or quickly.

Meanwhile, almost all routine healthcare operations in the country had shut down.  Prenatal care was not available, childhood vaccines were not being administered, hospitals and clinics were shuttered, and patients with HIV and TB did not have access to treatment.  Mortality from treatable diseases sharply increased. 

The need for region-wide coordination was obvious.  The concept of an Ebola Command Center, with centralized information and coordination, was born.  King’s S/L Partnership volunteers were the brains and brawn of the center's creation. One of these early champions, Amar, recently took me through the Center and described some of the struggles and challenges of that critical time.

The first step was to understand the magnitude of the problem – making the numbers of the epidemic known - numbers of patients (suspected, probable, confirmed), numbers of case contacts, numbers of ambulances, number of beds at Ebola holding units and treatment centers, numbers of burial teams.  The idea was to put up white boards in the Command Center, initially a dank cramped and windowless office, with these numbers in real-time.

Almost immediately, the idea was met with local resistance.  There is incredible power in numbers; public health interventions and outcomes hinge on good data. But real, hard numbers can be frightening; there is a false security in ignorance.

It was a hard-fought battle, but at the Command Center, these numbers were finally made public – and they were shocking.  So many cases.  So few beds. 

Gradually, incrementally, the two or three volunteers who had founded the Command Center garnered support.  Over the next few weeks to months, the Royal Sierra Leone Armed Forces and the British military joined the efforts.  The Centers for Disease Control and World Health Organization came on board.  NGOs rallied.  The Command Center moved from the cramped office to a large conference room with vaulted ceilings, with integrated computer system and official signage designating the three pillars of Case Management, Safe Burials, and Surveillance.  A call center was created and social media churned out billboards and posters encouraging people to dial 117 with any suspect cases.  It may have been a bit premature – the call center was completely overwhelmed for weeks, but it was a start.  Slowly, Ebola Treatment Units were built and beds opened up.  Finally in November, the epi curve (number of new Ebola cases) started decreasing.  By mid-January, when I arrived in country, the numbers of new cases were falling precipitously.

************

Having arrived late on the scene of this Ebola epidemic, I keenly feel the guilt of someone who came too late to be of much help.  Yes, the Ebola holding unit at the hospital is still usually full of patients, but few now have Ebola. 

This is a time of transition – scaling down disaster relief, and turning attention to the chronic, systematic needs of a country whose healthcare infrastructure has been shattered.

For me, a tiny cog in the wheel, it is hard to know where I fit in this time of transition.  I’m not seeing the loads of Ebola patients that I expected, although working in the Ebola holding unit is still intense.  The needs are now greater on the general hospital wards; patients with HIV and TB who need treatment and care.  Public health systems are beginning to grind to a start.  Other hospitals and healthcare facilities need support as they open slowly, cautiously.

I have three weeks left in Sierra Leone.  Three weeks can be a lifetime in the timescale of disaster relief, but it is only an instant in the timescale of effecting real healthcare system change. 

I am starting to wonder if I shouldn't ask to go home a few weeks earlier than planned, given that the Ebola crisis seems to be largely over.

Day 10

28.01.2015

Screams of a grieving mother break the morning calm.  Death is very visible here.  Every day, inside and outside the Ebola holding unit, patients die.  On most days a taxi will drive into the hospital with a corpse in the back seat; we carefully note “Dead on Arrival” in our large notebook of Admissions, Discharges, Deaths.  We bring the body into the holding unit morgue and obtain an oral swab to check for Ebola; a burial team comes to collect the bodies each morning. 

Grief is loud and public, and often involves a screaming female mourner physically restrained by others.  Frequently, the body of a patient that has died on the general wards is wheeled on a rickety hospital bed through the grounds to the mortuary. Onlookers rise to a stand, a silent gesture of respect, watching the corpse wheel by.

Those patients that survive to discharge from the Ebola holding unit often face enormous challenges.  Of course, Ebola is not the only illness here.  Cardiovascular disease, cancer, diabetes, and sickle cell are ever-present, as well as many other infectious diseases.  HIV, malaria, and tuberculosis are the Big Three, but many vaccine-preventable illnesses are now on the rise after almost a year of no public health interventions, including routine vaccinations.  Few hospitals are open; those that are function on a skeleton crew of young, often unsupervised, house officers. 

This week, we admitted a young woman to the Ebola holding unit for diarrhea, vomiting and malaise.  She looked chronically ill; HIV or TB seemed much more likely than Ebola.  She tested negative for Ebola, and was discharged. 

But she was still too ill and too weak to walk.  We requested a direct admission to the general wards.  “No beds,” came the expected response.  Pervasive fear of Ebola often makes it very difficult to obtain general hospital admission for patients discharged from the Ebola holding unit, even when they can pay.  And this patient, without family or financial means, could not. 

The young sick woman was left outside on a bench to pass the night. No beds the next morning either. 

Almost all medical care in Sierra Leone is ‘fee for service’.  Before a hospital admission, a registration fee must be paid.  Before the doctor sees a patient, a doctor fee must be paid.  Each tablet, each injection, each catheter, each lab requires a fee paid up front.  If there is no one accompanying the patient to advocate and pay for the patient’s needs, no treatment is provided.  More often than not, the nurses station looks more like a cashier’s desk, covered with bills and account books. 

In mid-morning, we are in the green zone ‘office’ when we hear a commotion outside.  Maintaining a safe distance, a small crowd has gathered around the young woman who is seizing on the cement floor, tonic-clonic movements, frothing spittle at the mouth.  Probably toxoplasmosis, cryptococcus, or TB meningitis.

I go back to the hospital senior staff to plead that the patient be immediately admitted for evaluation and treatment.  A bed suddenly materializes.  I write a careful referral form, recommending HIV testing, basic labs, chest Xray, sputum for TB testing, LP.  We start the complicated, protracted process of qualifying the patient for ‘destitute funds’, which requires tracking down senior staff for multiple signatures.  Two days later, the patient is receiving expensive antibiotics in the wards that she probably doesn’t need, the paperwork hasn’t been signed, and she still hasn’t had an HIV test. 

The obstacles to providing quality medical care here sometimes seem insurmountable. The needs are enormous.  The system and culture of the current healthcare system needs a fundamental change. 

The organization that I am volunteering with, King’s Sierra Leone Partnership, was created to strengthen the healthcare system in Sierra Leone through long-term partnership with local leaders and healthcare providers to develop organizational structures, resources and commitment to improving health.  

I believe that consistent efforts driven by this philosophy can achieve the seemingly impossible goal of delivering quality healthcare here.  But each day toiling toward that goal is a challenging and heartbreaking process.

Day 7

25.01.2015

My temperature is 101, and my abdomen cramps painfully. I have many explanations for this.  It was a particularly warm day today.  I worked out earlier – morning run, then lifting weights in the local hotel gym.  I got a bit of heat exhaustion being out in the sun, maybe a touch of sunburn.  I had a few bouts of loose stools in the past few days, almost certainly run-of-the-mill traveler’s diarrhea.  A low-grade fever is not surprising.  But I can’t deny that if I came into the triage tent right now reporting fever, abdominal pain and loose bowels, I would be admitted to the Ebola holding unit for testing.

I carefully review my actions over the last week.  No known breaches of PPE in the holding unit.  Very limited physical contact with anyone outside the unit; shaking hands and social touching has become taboo in Sierra Leone since the Ebola outbreak.

My suspicion that I have Ebola is very low, almost zero.  Nonetheless, I am sitting on the edge of my bed, obsessively checking my temperature every 5 minutes.  I pop some ciprofloxacin from my travel medicine kit.

I start meticulously outlining all contacts in the last 48 hours, since the time of my first symptom onset.  In the off chance this is Ebola, this information will be critical to the contact tracing team run by the Centers of Disease Control (CDC).  Running through the events of the last 48 hours, I can think of 26 possible contacts.

I check my temperature again – still 101°F (38.2° C). 

Per our organization’s protocol, I call the doctor on call.  Keeping my voice steady, I outline my symptoms.  We discuss my options – I can stay quarantined in my room with strict orders to call again if symptoms progress, or I can go to the Ebola Treatment Unit (ETU) just out of Freetown which is designated for ill healthcare workers.  This ETU is run by the UK military and boasts state-of-the-art facilities.  I would be admitted to the ‘suspect tent’ where my blood would be tested for malaria and Ebola, and my stool for common pathogens.  I would get a line and IV fluids and any needed supportive care.  It’s a comfort to know such a place is close nearby, but it rankles that the standard of care is so different for me, a mildly ill Western aid worker, than for the many far sicker Sierra Leonese patients that come to our facility for care. 

I opt to stay in my room and re-evaluate in the morning.  I don't sleep well, but in the morning my temperature is down to 99.6°F (37.5°C) and my symptoms are tapering off.  A boring day at home, and I am ready to be back at work the next day.  

In the era of Ebola, even a simple febrile illness causes much anxiety.

Day 4

22.01.2015

This morning my plan was to walk briefly through the unit to introduce each patient to a newly arrived colleague.  We did not make it past the corpse in the second room.

I had admitted the patient yesterday from the triage tent.  He was a kind, well-spoken, middle-aged man, dressed in traditional Muslim garb.  A careful first look revealed several signs suggestive of Ebola infection: bloodshot eyes, painful hiccups.  He said that three days ago he had developed sudden onset fever, sore throat, overwhelming fatigue, and abdominal pain. I did not have to think twice before escorting him to the holding unit where his blood would be tested for the virus. I completed the admission paperwork and pulled on the layers of PPE before entering the unit to administer admission medications – ceftriaxone for possible bacterial infection, artemisinin for possible malarial infection, paracetamol for pain, metoclopramide for nausea and hiccups.  He looked sick and panicked.

Still, I was caught off-guard the next morning when I found him dead on the cot.  Long minutes feeling for a pulse, looking for a response to a deep sternal rub … nothing. After covering the body with a sheet, I told the other patients anxiously looking on from their beds that he had died.  We poured chlorinated water over the body and lifted him to a body bag on the floor. My muscles strained with the weight as I picked up one end of the stretcher and walked to the morgue.  

Back in the disinfectant room, we scrubbed our hands with extra vigor, knowing that infected corpses have incredibly high levels of Ebola virus.  Touching dead bodies carries one of the highest risks of Ebola transmission.

A few hours later, the deceased man’s young wife and father arrived to inquire for an update on the patient’s condition. No HIPAA  patient privacy regulations here; we stand in the center of the busy covered entrance to the hospital.  “I’m so very sorry, but he died this morning.  We are still waiting for the Ebola test results.” The father looked at me in mute disbelief and walked away. The wife stumbled to the sandy curb outside the hospital gate; wails and prostration; grief, intense and unreserved.

The blood test came back highly positive.  The burial team came in an ambulance to take the body to a guarded Ebola cemetery. The family could only watch from the fence, forbidden to perform customary funeral rituals.

In much of West Africa, funerals are of great cultural significance.  Merit as a person, as a family, is determined by how many people attend one’s funeral.  It is also widely believed that the recently deceased provide unique access to one's ancestors.  A funeral provides an opportunity to reconnect with the ones you have lost and to keep favor with departed souls.  Family and friends of the deceased demonstrate respect by cleaning the corpse and mourning physically over it. These beliefs cut across religion and socioeconomic status.

Due to the highly contagious nature of a corpse infected with Ebola, funerals of Ebola suspects have been banned. This policy has met stiff cultural resistance.  Frequently the family of a deceased person in our Ebola holding unit will gather in large numbers, pleading for us to release the body for a family funeral, sometimes tearful, sometimes angry, sometimes threatening. These conflicts between public health and longstanding tradition are emotional and difficult.  It is hard to deny a funeral to a mourning mother and not feel heartless.

Ebola strips people of their dignity, in life and in death.

Day 2
20.01.2015

First day in the red zone. The unit is divided into 3 areas: green, orange, red. Green is the office; a huge white board takes up one wall, outlining details of the patients in our 15 beds. The office is busy with staff and personnel; it takes a team of about 8 providers and cleaners to run each shift of this complex operation. Orange zone is where we change into personal protective equipment (PPE); red zone is the patients’ quarters, the morgue, and the decontamination area.

I am in the orange zone with a colleague, suiting up. I tuck my scrubs into rubber boots and step into the white, hooded Tyvek suit, then cover the front with a white plastic apron. Next, mask with face shield, sprayed with essential anti-fogging solution. Double layer of long gloves that reach the elbows. Check in a mirror, then check my colleague.

Me in full personal protective equipment (PPE), ready to enter the red zone.

My scrubs are already drenched with sweat; a trickle starts down my spine. We step in a shallow basin of chlorine, then into the red zone, moving very deliberately despite the heat. One can tolerate the heat and claustrophobia of PPE for only so long; we try to spend a maximum of 2.5 hours at a time in the unit to avoid heat exhaustion.

We make our rounds on the patients, administering medications, encouraging hydration. One new admission, a young man, relatively well and unlikely to test positive for Ebola based on his symptoms, beckons me over to tell me I look like the devil. I’m sure our white suits have many negative connotations for the patients; I try to explain in broken Krio that I wear the suit to protect him, not just me.

Just a few weeks ago, over half the patients in the unit would test positive for Ebola. Now, thankfully, the number of positive cases has dropped, likely due to a culmination of efforts to improve country-wide coordination. Several new Ebola Treatment Units (ETU) opened up in the Freetown area recently too, making it possible to truly isolate positive cases, breaking the chain of transmission.

Only recently has this unit been able to be the ‘holding unit’ it intended to be. The new ETUs make it possible to quickly transfer out patients who test positive for Ebola, reducing the risk of transmission to Ebola-negative patients in the unit.

We finish our rounds and head to the decontamination room. Methodically, meticulously, we pull off the layers of protection. Between each step, we wash our hands under running chlorinated water, watching the second-hand on the clock to make sure we don’t cut corners. The process of PPE removal, better known as ‘doffing’, takes about 20 minutes. The hint of a breeze on my face after removing my face shield is utter bliss.

 
Day 0
17.01.2015

The burgeoning Ebola epidemic in West Africa in the summer of 2014 captured the world’s attention, and my own. Initially I did not seriously consider volunteering, as I was still nursing my infant daughter.  But in mid October, as the epidemic grew larger than ever imagined, I found myself reading an article (Farrar & Piot. 2014. NEJM 371:1545-1546) that stressed the immediate need for a “massive increase in response”. By the time I finished reading the paper, I was convinced that I had to try to be a small part of that response.

It is surprisingly hard to get a foot in the door of disaster relief.  I applied to about ten organizations, most rejecting my application without review, due to ‘lack of disaster relief experience’.  I finally got a few positive responses and went through rounds of interviews, applications, psychological evaluations and reference/background checks before being offered positions with two different organizations.  I chose to work with King’s Sierra Leone Partnership (kslp.org.uk), an academic group out of the UK which has been partnering with the Sierra Leonese providers at Connaught Hospital since 2011. 

People at home have asked in baffled tones why I want to go.  I am no hero and have no illusions that I will even be able to play a significant role in this epidemic. The fact is that Ebola has ravaged the ranks of healthcare workers in West Africa, with very few trained local people left. If I, with a background training in medicine, infectious disease, epidemiology, public and global health, do not volunteer to care for these sick patients, who then should?

Today, I fly to Freetown via Washington DC, Brussels, Dakar and Conakry with conflicting emotions.  A young child, about the age of my daughter, babbles across the aisle, making me wonder if I really belong here, hurtling across the Atlantic at a cruising altitude of 32,000 feet. 

But this is public health: to contain an outbreak at its source to keep the greater population free of disease.  In a small way, perhaps this work will provide a safer, healthier world for my daughter.