F**k you, Ebola

Read in:

05 February 2016

Months of talking, over a year of reflecting, and finally on Wednesday 6 January we entered officially into Magburaka Government Hospital working alongside the Ministry of Health, immediately boosting the clinical teams in maternity and paediatrics and supporting their life-saving activities. 

Our international presence is small, but we are highly motivated and fortunate to have developed a strong relationship with our Sierra Leonean colleagues. 

There are many events I will remember from that first weekend: introducing new team members to those who have been in the hospital for years, trying to maintain a culture of training, and encouraging experienced staff to mentor those who are newly qualified. I will also remember the first of three newborn babies to present with neonatal tetanus, watching his tiny face scrunch-up in pain as his muscles uncontrollably contracted, our presence enabling the hospital to deliver medicine, analgesia and care for him.
 
In maternity the ambulances kept coming, sometimes two patients squeezed in the back together, often with long and complicated labours. There were several women with ruptured uteruses, one needing an emergency hysterectomy, a teenager in labour for days, who subsequently developed a fistula and a woman who came with a massive placental abruption, a haemoglobin of four and needed emergency surgery. We also had to call in extra help into the hospital at night to stabilise one patient whilst we operated on another.
I will remember too, that no woman died and no baby survived.
 
That first weekend will stay etched in all our memories, not only for the patients we saw but for those we didn’t see too.
 
Whilst we were busy in the operating theatre with a 16-year-old girl whose body was fighting with her unborn stillborn child, a 22-year-old woman came to visit the outpatients.
 
The woman had travelled from another part of the country, she presented with vague and general symptoms. She was seen by Ministry of Health staff, sent for some tests, and went home. 
 
She died three days later at a family home in Magburaka and then had a traditional burial. As with all deaths in the country she was swabbed for Ebola before burial. 
 
Thursday evening we gathered together for a team meeting, the mood was good. One week into the project and the teams were working-out well. We made a brief toast as the WHO was due to finally announce the Ebola outbreak in West Africa over. 
 
We first heard rumours that the swab was positive approximately 10 minutes later.
 
Imagine, suddenly you are no longer just in a hospital in Africa; you are at the centre of the world and everyone is watching your next move.

A nurse counts tablets in the MSF Ebola survivor clinic in Magburaka in November 2015. © Tommy Trenchard

There are few of us in the project who were here during the peak of the outbreak, a time of huge loss and heartbreaking sights. Paranoia swept through the minds of whole societies, the loss of rationality and massive increases in mortality. 
 
When Ebola first visited back in 2014 no-one knew what to expect, and though we tried to withstand the force of the disease and find ways to keep going, it was ultimately stronger than us.
 
Closing the maternal and child health project back then was the safest decision, given the uncontrolled situation, but still remains a painful one for many of us. It is also that experience that kept so many of us returning during the outbreak, and talking, arguing and pushing for the need to create a project that was set-up to withstand another outbreak. 
 
Turns out the test was on our own doorstep, less than a week from opening.
 
The rumour mill in Sierra Leone is incredible, knowing who to ask can get you information much earlier than official announcements. 
 
At 5am the next morning a small group of us got up and quietly left for the hospital in the dark. The confirmation had not yet come, but all the town knew. 
 
We made our way from ward to ward, checking on every single patient, regardless of whether they were part of the MSF project or not. We talked to all the staff, ensuring there was sufficient protective equipment, hand washing and observations for any worrying signs. 
 
We re-traced the flow of patients through the hospital and put plans in place for isolation facilities. We already had a tent at the front gate, this was expanded and teams were put together in case any cases would need isolating. 
 
Pregnant women and children are especially challenging groups in an Ebola outbreak setting, lessons of the past kicked into action. Separate isolation areas, thought out according to their needs, were quickly discussed and set-up. Before the sun had risen, before the world was told, we were there preparing and implementing. This time we were not going to be behind Ebola, we were putting up defenses and we were getting ready to fight. 
 
Three words we all knew, “Fuck You, Ebola.”

The entrance to the Ebola Management Centre in Magburaka in March 2015. © Sophie McNamara/MSF

The challenges though were the same. I previously wrote that Ebola is more than a disease, it is a state of mind. The pressure to “catch” patients is huge, and soon everyone is guilty till proven innocent. The outcome being many (mostly pregnant women and children) dying for nothing other than seeking healthcare. 
 
Prior to this case we were screening all patients for signs that could indicate the disease, however this is a fine art and an even finer balance between help and harm. The definition of Ebola suspicion changes according to the context you are working in, the non-outbreak setting accepts that most people will not have Ebola and focuses on non-response to treatment. 
 
However, once a case is confirmed the definition reverts to outbreak, which is wide and general, and if not carefully applied with scrutiny of patients and their symptoms, can result in the unnecessary isolation of many sick (and easily treatable) conditions. We carefully question each patient, and use universal precautions for everyone. But this takes time, and can lead to delays in treatment.
 
When the official announcement finally came it was of no surprise to any of us. The reactions were mixed, some were thoughtful, lost in their memories of the past, others were motivated and pumped for action, and some just philosophically took it onboard and then continued with business as usual. 
 
I had assumed our fledgling project would suffer and that new staff would not come to work, I was wrong. Everyone came, and the team has stood taller and stronger than I would have ever dared to expect.
 
The decision to isolate a patient carries huge responsibility. Labelling them with Ebola, treating them in a tent and only whilst wearing the restrictive protective suits. It is vital to interrogate the patient’s condition so that a safe and rational decision is taken. Many of us have found that continuing non-Ebola healthcare is the most difficult aspect of working in an Ebola outbreak.
 
On Saturday, I had just come home for a break when I was called; there was a difficult case at the screening tent. I returned to find the team struggling with an isolation decision. A nine-year-old girl had been brought by her mother with a high fever, weakness, difficulty breathing and not eating.
This meant she had enough symptoms to meet outbreak case definition. The girl was visibly very sick, most probably with severe malaria, in her critical condition isolating her would limit the care she could receive. 
 
If we did not isolate her though we would be risking a very precarious situation. We questioned the mother again, she sat across the orange plastic fence from us with her daughter in her lap. Lovingly supporting her head she looked at us, the defendant facing the judge and jury. We searched for a way to justify the decision, but we knew we were cornered. Together we agreed to isolate her and then immediately begin resuscitation, intensive antimalarial and broad antibiotic treatment.
 
Ebola demands speed control, nothing happens fast. As we got prepared to isolate, putting the protective clothing on, the girl’s breathing slowed, then stopped. 
 
The mother still sat opposite us with her daughter in her lap, face-to-face with us and our decision. We could not touch her, we could only throw a cloth over for her to wrap her daughter’s body as she murmured and sobbed. The child had been labelled a suspect and we needed to maintain cool clinical management. The body had to be treated as if Ebola positive and the whole area decontaminated. The posthumous test was negative. 
 
Ebola is a cruel disease, not only for the illness it causes but for the collateral damage it forces us to be a part of and bear witness to. 
 
The tests of conscience, ethics and clinical judgement kept coming. Each one we discussed and relied not only on the proforma in front of us, but on our professional acumen and personal experiences. There is no perfect, but there is being human and trying to do the best that can be done in a far from perfect situation.

A nurse prepares drugs for the day in the MSF Ebola survivor clinic in Magburaka in November 2015. © Tommy Trenchard

Early Wednesday morning news came that a woman who had cared for the person with Ebola was going to be sent to us for assessment. We had been expecting that sooner or later contacts of the first case might develop symptoms. 
 
The challenge would be making sure she could be assessed and cared for, whilst maintaining normal hospital services. In the previous outbreak we saw the number of patients at the hospital dwindle whenever a case was suspected, that has not happened this time. Maternity and paediatrics remain busy, emergency cases continue to come and care is being safely delivered. 
 
We managed to discreetly admit her into isolation, away from prying eyes and far from other patients. There are some characteristics to Ebola infection, a certain way of moving, a look in the eyes and lethargy. They can be subtle, but they are also recognisable. The test was taken, but we already knew what the result would be.
 
The concept of the project was now being truly tested. Isolating the only suspect Ebola case in all of West Africa, while running busy general healthcare. 
 
A woman with twins was in labour, but they were not coming. She had been injected in the community with a high dose of oxytocin, a common problem often resulting in ruptured uterus. The twins were “locked” together, a rare complication that put all three of their lives at imminent risk.
 
Together as a team we rapidly got her to theatre and delivered the babies, all three of them alive and now safely home. In-between managing the screening and isolation we continued to see ambulance after ambulance come. 
 
The woman tested positive, we mobilised counsellors to get the news to her before the local gossip spread. We then transferred her to the referral centre in Freetown that evening. The day was not over though. Three more maternity ambulances arrived; obstructed labour, severe eclampsia showing life threatening signs of organ failure and then another woman with a ruptured uterus.
Isolating and testing for Ebola, whilst a stone throw away we continue to perform emergency surgery, resuscitate mothers and babies in the country with highest mortality figures in the world. That’s right; “Fuck You, Ebola.”
 
Despite being the last place with an Ebola outbreak, we are seeing an increase in patients. The opposite of what was experienced the last time around. 
 
More women are coming to stay at the end of pregnancy to wait for a safe delivery than ever before, word has gotten out that Magburaka Government Hospital offers quality care, and we (a partnership of Ministry of Health and MSF) do so with pride. 
 
Late on Friday night three of those waiting went into labour, one woman from a remote village birthed twins, another had her eleventh child. The third woman, a 25-year-old in her seventh pregnancy, had no living children. 
 
She had cried with fear, afraid to push in case history returned again. United we supported her, gently coaching her through. The baby came with cord tightly round the neck, calmly and quietly we helped him breathe. The girl then had a massive haemorrhage. We got her to the operating theatre, eventually managing to stop the bleeding.
 
If there is any symbol of this last two weeks it is the image of this short woman looking contently at her healthy boy, being cared for in the proud arms of his grandmother.
 
The ability to respond from within our own team, alongside the professionalism and resilience of our colleagues has turned the dream into a reality. 
 
We have seen what this horrible disease can do, and we are committed to not let it disrupt the vital services we are supporting the hospital to provide. 
 
There was no emergency team, there was no influx of international staff or trucks of supplies. We have managed with what we have and who we have, the same as the day before and the same as tomorrow. 
 
Ebola came and showed its ugly face again, but I am glad it came to where we are. Together, national and international we have stood firm. 
 
One woman died from Ebola in the last month, but many lives were saved.