In mid-January, I left home and hearth to join an Ebola Response Team in Sierra Leone through Partners In Health (PIH). Like PIH's stated reason for mobilizing during this humanitarian crisis, I felt morally compelled to do so given my medical background and familiarity with the language, climate, and culture of Sierra Leone. My familiarity with the country is due in large part to my two-year service as a Peace Corps volunteer.
Perhaps it is common knowledge now that Sierra Leone has one of the weakest health care infrastructures in the world. This translates into, among other statistics, an infant mortality rate that hovers around 20 percent and a maternal mortality rate during labor of about 12 percent.
Add in poor road conditions, lack of reliable supplies or supply chain, irregularly paid medical personnel and the recipe for disaster is complete when a highly infectious disease like Ebola enters the scene. The spread of the Ebola virus in Sierra Leone was further fueled by funeral practices that exposed grieving community members and family to highly infectious body fluids. And, let's not forget the hundreds of frontline Sierra Leonean healthcare workers who were exposed to and died from Ebola virus disease, while treating infected patients without proper protective equipment.
Partners In Health began deploying short and long-term staff to work in Ebola Treatment Units, the Princess Christian Maternity Hospital in Freetown, and the quickly evolving front line Community Care Clinics (CCC's) in Port Loko and Kono Districts. The stated goals of the Ministry of Health and the non-government organizations involved in the Ebola Response is three-fold: stop the spread of Ebola by screening every individual who is ill, isolate any person who meets "case definition" meaning that their symptoms might be consistent with Ebola virus disease and continue their care on a suspected case ward while awaiting lab results, and, lastly, provide a safe environment for both staff and patients.
So, patients are admitted into a zoned complex where there are strict procedures for putting on and removing the protective equipment, performing duties in a clockwise fashion from ‘suspect’ wards to ‘confirmed’ wards and then exiting. Discharge criteria are also in place for patients who do not have Ebola, those who have survived the infection and removal of the bodies of those who have succumbed. Contact tracing is a key component of the effort with health workers tracing and tracking those who have been potentially exposed to the disease in the community.
Each team member goes through extensive training before being allowed to enter an Ebola Treatment Unit or Community Care Center. The World Health Organization conducted our training in Freetown over a three-day period where we reviewed Ebola Virus Disease, case definition criteria, and supportive therapies currently being employed.
A mock ETU was set up and we became acquainted with moving through the unit treating patients in the space suit like personal protective equipment (PPE) you have seen medical workers using in video footage. So, about that part—there is nothing in my personal or professional life experience that could have prepared me for putting on PPE near the equator on a hot, dry season afternoon then walking through an enclosed, breezeless, dim, mock treatment unit with mock patients lying in various states of deterioration, mock latrine pails at bedside, mock body fluids on the floor and other hazards. Then, there was the final sobering room in the confirmed section where there was one live patient ready to go home and one deceased patient needing to be processed for safe burial. Sobering, indeed.
What does getting into a spacesuit (PPE) look like, you might ask? Well, something like this: remove all adornments and items from pockets - anything that goes into the ETU beside your scrubs and boots, stays in the ETU and will be burned. For patients, that means burning money and cell phones and all clothes and possessions upon discharge at which time they are given new everything. Pre-hydrate! Check your equipment to make sure there are no holes or rips. There are variations to the theme, but one dresses in the following order: spacesuit, first pair of gloves, apron, second pair of gloves, hair net, face mask, pull hood over head and adjust face shield. Your partner will watch you put everything on and check that you have no exposed skin then write your name, position, and time going in on your apron.
By now, before you ever enter the unit, sweat has begun in a trickle fashion toward your boots and collects in your facemask. Find your happy place, then enter the red zone with your partner. Wend your way through the suspect ward, then confirmed ward providing care and troubleshooting problems.
After 60 to 90 minutes, head toward the ‘doffing’ area where you can remove your PPE over about 15 minutes. Doffing (removing the PPE) is the most likely time to inadvertently become exposed to infectious material and the process is very methodical removing each layer and washing hands for one minute in between every step. It's best not to stay in the suit for so long that you are unable to concentrate during this process. We strongly discourage "cowboy" attitudes and see them as inherently threatening to the safety of the whole team.
So, thus free of the space suit, you can take your sweat-saturated body to the break room for oral rehydration solution and a snack. The team then develops a patient care plan for the next team entering the ETU or CCC.
Thus was my training with the World Health Organization staff and then in the Port Loko District ETU run by Partners In Health and the Ministry of Health.
Shortly after my ‘hot zone’ training, I was transferred to Kono District in the far eastern part of Sierra Leone. Though the number of confirmed Ebola cases have dropped precipitously in this part of the country (as of this writing there have only been two in the last three weeks), the Health Ministry remains on high alert for the possibility of sporadic cases so that the ill persons may be isolated quickly and prevent further spread. There is guarded optimism with a proposed plan to close the Community Care Centers and reopen schools by mid-March or April.
In the context of that optimism, the Partners In Health mission has also begun to shift from response to recovery and then, ultimately, to strengthening the healthcare infrastructure by partnering with the Ministry of Health over the next decades much as they have done in other countries such as Haiti, Rwanda, Peru, etc.
My role as an Ebola Response Team member is also changing as I participate with a team in managing, training, and coordinating staff at the four CCCs in the Kono District and begin laying the foundation for transitioning the care provided at the CCCs to the local Peripheral Health Units and other health centers, the equivalent, if you will, of satellite VMH Clinic such as the Kickapoo Medical Clinic in Soldier's Grove. Undoubtedly, this is a long-term commitment to a health care system that is perpetually overwhelmed. These health care entry points will also need to continue to perform Ebola screening and have an adequate system of isolation, supportive care, lab assessment and transfer if indicated.
I have also been fortunate to partner with the midwife at the WellBody Clinic (a Partners In Health partner organization) in Koidu on antenatal care days providing consultation services, continuing medical education and also continuing education on using the only functioning ultrasound in this section of the country.
My fluency in Krio, the common language, and familiarity with the culture has been instrumental in facilitating relationships with the local staff. This has translated into a gratifying and steady trajectory toward improvement in infection prevention and control and delivery of health care to a chronically marginalized population.
I'm proud to represent my family, community and Vernon Memorial Health Care in the effort to support the people of Sierra Leon during this crisis and greatly appreciate the support and prayers and general consideration afforded my family and I. Thank you!
Varnes-Epstein is a physician assistant and mid-wife living in rural Gays Mills.
