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.