Before arriving in an Ebola project, most MSF expatriates have to go through two days of intensive training. An important part of this is putting on the full personal protective equipment (PPE). Dressing up for the first time is incredibly uncomfortable, essentially covering your entire body in plastic, tying a waterproof hood around your head, with an N95 respirator mask that protects your mouth protruding through a slit in the mask of the hood. Only your eyes are exposed and then you wear goggles. On top of the yellow suit is a thick waterproof apron and your feet are covered in heavy rubber boots that protect against penetration inside the high risk area. All of these items have to be of a certain standard to ensure a high degree of protection and minimize the risk of infection. Depending on the environmental temperature at the training center, you start perspiring inside the PPE and begin to feel your green cotton scrubs become damp underneath the suit. This is all part of the initiation and no one enjoys their first experience. You’re told that you will get used to it, and after ten days be quite comfortable in PPE but I think that has more to do with a mental shift that takes place in order to continue working and fulfill responsibilities inside the high risk area than a physical adaptation.
Field conditions are often much more challenging. For one, the environment is extremely humid and you are already perspiring before putting on the PPE. The first item is a pair of latex gloves and you must get used to the feeling of latex clinging to your damp hands so that you can continue dressing. The last item is the goggles, you want to spare as much time, even if only a few minutes, before putting it on because it mists up inside, obstructing your vision so that high risk procedures such as drawing blood for routine tests or administering intravenous fluids become almost impossible. The longer you stay inside the PPE, the more you sweat and on some days it feels as if you’ve lost up to 2 liters of fluid as your scrubs are drenched when you undress. To prevent people collapsing with exhaustion, no one is permitted to be inside for longer than an hour, but the discomfort starts long before this. You start feeling sweat running down your body, the respirator gradually becomes soaked and is sucked into your mouth as you inhale.
Since the face protection in not breathable or absorbent, sweat runs down your face and bending forward can cause droplets to drip off your eyelashes onto the goggles. If water collects in the respirator it also feels as if you’re exhaling underwater. At some point, the top tie of the hood becomes a tourniquet around your head and it hurts. It takes a few rounds of PPE before you silence the voice in your head telling to you rip off the goggles. In fact, you have to consciously remind yourself not to touch your face while in PPE inside the high risk area to avoid contamination. But all of this is bearable if you know why you’re in it, so going in with a purpose helps. Another big motivation to put on PPE and make sure it’s on properly are the stories of how vulnerable health care workers got infected with Ebola and died. Many didn’t know what they were dealing with until it was too late and others were simply not adequately protected.
Musa Kenie, a 24 year old community health officer from Kailahun, Sierra Leone working at MSF’s Ebola case management centre (CMC) in the district says the country has suffered a huge loss of health care workers, especially amongst those who were community-based, such as nurses trained in maternal and child health. In a country where the maternal mortality rate is one of the highest in the world, this is devastating. Musa tells me about his first encounter with a patient suspected of having Ebola at Kailahun Government Hospital on the 17th of May this year, “My colleague mentioned that there were rumors of an Ebola outbreak in Koindu, the border town near to Liberia and Guinea, and this is where the patient came from but we did not suspect Ebola even though she had a high fever, postpartum bleeding and was confused.” The only protective equipment Musa and his colleagues had at the time were elbow-length obstetric gloves, no face masks, no goggles, no apron, no rubber boots. He attempted to insert an intravenous cannula in the patient’s arm while going through all the possible causes of postpartum bleeding, trying to find a diagnosis but Ebola was still not on the list of differential diagnoses when the woman died more than 12 hours later.
On the 20th of May, Musa was sent to train under a senior colleague for six months in Buedu, a town 17 miles away from Koindu, before being posted to his own catchment area. But in Buedu community health centre he found four patients isolated in the maternity ward with the same symptoms: fever, vomiting and diarrhea. “Now we were thinking of cholera,” he says. Within a day of his arrival, surveillance officers from the Ministry of Health and Sanitation arrived to take blood samples from the four patients. This time they wore aprons, face masks and gloves. Musa was informed of similar cases in Koindu and that blood samples from there would also be sent to the Hemorrhagic Viruses laboratory in Kenema. If the results were positive, he was told the government would declare an Ebola outbreak in Sierra Leone. And shortly thereafter, that’s what happened. Almost six months later, we stand in a clearing in the forest used to bury those who died of Ebola at the Kailahun CMC. It’s a field of unmarked graves containing bodies of people from different parts of the country. Most of them died alone and were buried before their families could identify them. One grave is marked by a wooden sign board with the words “RIP Rosaline Kamara” handwritten in red paint. Rosaline was a friend of Musa’s and a maternal and child health nurse aide who was admitted to the CMC but didn’t survive. Making the sign board was Musa’s way of honoring her memory beyond the statistics in the wake of Ebola’s indiscriminate attack.
Its true that nothing I read about Ebola or heard from my colleagues in the field could prepare me for the reality of it. Even when I’m certain that my PPE will protect me from being infected by the virus, I cannot escape being affected by the pain, loss, helplessness and unfairness of it all. It’s not the wide-scale effects that ultimately penetrate one’s illusion of separateness, not dead bodies or death rates or sick people falling out of an ambulance at the entrance of the CMC. It’s the more subtle experiences of having to isolate family members when someone tests positive and the others are negative, then witnessing their grief and anxiety when they’re separated from each other. It’s in the profound sadness we feel for children who refuse to eat or speak as an expression of their acute despair after seeing one or both of their parents die in adjacent beds. It’s the cold precision with which infection control measures are enforced and the way in which these violate what makes us human, like barring a mother from breast feeding her baby or denying those left behind much needed closure of funeral rites for their dead relatives. And sometimes it’s a hopelessness and loss for words when we find out that another healthcare worker has died.
Poverty, underdevelopment and weak health systems are amongst the reasons this outbreak has claimed so many lives, so it makes sense that in the absence of any radical treatment the care that MSF provides to Ebola patients is centered on oral rehydration, nutrition, hygiene and a standard course of antibiotics and antimalarials. With this regimen we’ve seen a greater than 40% cure rate at the Kailahun CMC, which is truly inspiring. I’ve been here for four weeks so far and despite hearing rumors and having expectations, I’ve not seen any Cuban doctors or American troops come to help where we are. While we impose restrictions and militantly implement universal precautions to secure our borders, West Africans in Sierra Leone, Liberia and Guinea are trying to make sense of the decimation and find a way to move forward after so much of the little that they had to begin with has been taken away. Not enough was done by the international community to avert the disaster and prevent the spread of Ebola at the epicenter of the outbreak. Six months later, with an increasingly punitive and fearful approach towards quarantine of those who’ve chosen to help, it appears as if the world’s response is still shamefully off the mark.