It is currently rainy season in Sierra Leone, the daily thunderstorms attack the parched earth. The large droplets bash the corrugated iron roofs creating a deafening noise, like thousands of steel drums being struck by an angry mob. Everyone and everything stops for the downpour. Having grown up in the North West of England I’m used to staying indoors because of the grim weather, but this is something totally different. The rain comes with such force it literally takes my breath. There is not much to do but wait the storm out, and pray that I’m not called out to maternity.
The sheer rage of the storm reflects to me the desperate state that we are in right now,trying to permeate through the different layers of society the reality of the epidemic slowly sweeping down the country. The resistance to believe that another health challenge, in this very challenged region, is evolving into a national disaster. Some of the loudest and longest storms feel like they will never end, but eventually they always do. The same is true of an Ebola epidemic, the natural history of the disease leads to violent outbursts of illness and death however it will ultimately burn itself out.
It remains to be seen though how far this storm will spread, and what will be left standing and what will be washed away.
I took a journey to the eastern region of Kailahun, which sits close to the borders of Guinea and Liberia, and is the epicentre of the ongoing Ebola epidemic. MSF has an emergency project in operation in Kailahun working hard to reach and assist the communities most deeply affected. There have been many worrying stories of local populations resisting efforts to contain the disease, on occasions turning violent towards the health workers. That was not my experience at all. As I reached Kailahun, the four-wheel drive lurching forwards and backwards over the mud roads, I was greeted by smiling waving children and adults nodding in acknowledgement of who I, and the car I was in, represented. It was clear that the vast majority were relieved to see they were not alone in this uncertain time.
The project is set on a large piece of cleared forest land, a logistical feat in itself to create a fully functioning unit with laboratory, wards and sanitation facilities in this remote area. Broadly speaking the area is split between low and high risk areas. Whether entering either, one must wash with chlorine, and if going into “high risk” dress-up in the full personal protective equipment (PPE).
I arrived in the midday heat; in my possession was a small package of vital importance. Blood samples of suspected Ebola patients. There is only a handful of labs able to run the necessary tests in safe conditions. Each sample is triple packed in sealed and chlorinated containers. Even knowing the strict precautions taken to package the samples, after fours hours of being thrown around on the uneven road l was keen to dispatch of the package as quickly as I could.
Having already experienced working with suspected Ebola patients (First 24 hours) and the routine of dressing in PPE, I was soon being asked to assist in the medical activities of the isolation unit. The unit runs as a one-way system, from lowest to highest risk. This way the person passing through cannot move the disease from a confirmed patient to someone waiting on a first test result. Adjacent to the dressing area is patient triage where suspects initially enter to be questioned about symptoms and any possible contact with other cases, from there they are stratified into whether or not they meet the criteria to be tested, and what level of quarantine they need go to.
Once I was dressed and goggled up I walked through the multiple red plastic fences into the high risk isolation area. There is something totally unreal with walking through an Ebola isolation unit. I had read and discussed so much about the disease that I was not expecting to be shocked. But I was. Not all Ebola patients look sick.
I have no intentions of underplaying the severity of this horrendous disease, but the fact remains that there seems to be two types of Ebola patients - the well and the unwell. I was ready for the pitiful sight of grown men weakened and dying, to see people wilted from profuse diarrhoea and external bleeding. And of course I saw those haunting sights, but I also found groups of young people sitting around talking and eating together, listening to the radio and playing cards. This was the other face of Ebola, the surviving class.
The unrelenting sun baked through my outer yellow plastic garment, letting all the heat in and none out. It is so hot inside the tents (used as wards in isolation) that the patients well enough tend to sit outside between the tents instead. Within minutes I could feel the sweat dribbling all down my body, and my scrubs (the third and most inner layer of clothing) becoming heavy and sodden. Trying to work in the heat is unbearable, coupled with the stress of the environment, stakes of getting it right and not exposing oneself to the disease is incredibly intense.
Once inside you have to rely on yourself and your “buddy” (you never go inside alone). We found we were missing a piece of equipment so I walked over to the inner perimeter fence and shouted out to the low risk zone. Explained what we needed and waited for someone to throw it over. Nothing is fast enough when you are cooking in PPE. Goggles slowly misting over and my head pounding from heat, salt loss and the tight goggles band. The equipment is thrown across the fence, once inside the high risk area it will never come back out.
After about 20 minutes I had to get out of there.
My head was spinning, I could barely see and was becoming increasingly faint.
Fainting in an Ebola isolation unit is a very bad idea. It is on leaving, rather than being in, the isolation unit that the greatest risk of transmission is posed to health workers. I am forever grateful to the stern Sierra Leonian hygienist who stood before me instructing the decontamination process. I stood with my finger circling in the air to show that I was getting dizzy, she ignored it. I was breathing rapidly into my double face mask, which just made me hotter and more aware of the claustrophobia, becoming increasingly frustrated that I couldn’t just pull the fucking thing off.
“Spread your arms” she shouted from behind the red line separating our worlds: contaminated and decontaminated.
The cool spray of chlorine washed over me (still in full PPE). “Turn”. Even though I was still in full suit, the relief of feeling the wash was immediately apparent; physically and psychologically.
“Wash your hands” at every step the hands (still in two pairs of gloves) need to be washed in chlorine. “Remove the gloves (outer pair), wash your hands, remove the goggles, wash your hands…”. Every step has to be meticulous.
Finally I’m standing de-robed, one final spray of the boots and I can cross the red line. A final wash of the hands in the decontaminated zone and I’m free to go and re-hydrate (I look like I just went swimming in my scrubs).
Despite the scale of the epidemic and work to be done, there is a lot of sitting around in the field site. Pre-hydrating, re-hydrating, discussing who will go inside when and to do what. With new patients arriving sporadically (often in groups of families or villages) and others leaving, either through the front door or the back door, there is always something that needs to done. The complication of needing PPE means that work must be carefully allocated and thought out ahead.
Occasionally everyone stops what they are doing;the doctors, nurses, and cleaners. Everyone. All attention is directed to the decontamination exit from high risk zone. A patient is being discharged. Like a celebrity the survivor is surrounded by an excitable crowd of whooping and clapping. The beaming faces of the crowd reflected in the broad smile and shining eyes of the survivor. It is an intensely emotional moment, though often bittersweet. Survivors of Ebola may be the only survivor from a family, returning to an unpredictable future. Will the community reaccept them without stigmatisation? Have their belongings and home been destroyed? Who is still living?
However, despite all the concerns, the sense of optimism and hope is insuppressible. With a presidential wave the survivor walks out through the gate into the unknown. On discharge they are each given new clothes to wear (nothing that goes into high risk comes back out), food supplements, psychological support and assistance from the health promotion teams. Men who survive, though no longer infected themselves, still shed the Ebola virus in their semen for three months after. They are given condoms to last the period, a popular topic of conversation is just how many one needs!
Everyone feels a huge sense of achievement during the discharge of a “cured” patient. But MSF does not cure Ebola, only an individual’s own body can win the fight. The medical care is supportive only, through nutrition, hydration and treatment of other infections (such as malaria).
Although I sense that the emotional and psychological impact of seeing that you are not alone, and of course witnessing the euphoric discharge of others, has an important restorative effect.
As the sun sets on the isolation unit and we prepare to leave for the night, the question in our minds is who will wake in the morning, and who will not. In epidemiological terms the sun is yet to begin its descent on this heartbreaking episode.
For all the political rhetoric of the last few months, it appears to be only now that the world is truly beginning to sit-up and try to grasp the unfolding disaster. I may not be qualified to give an opinion on why that moment has come now (and not several months ago), though it is unlikely to be coincidental that it has come with air travel transmission and the infection of Westerners. Apparently, global lifesaving interventions are also stratified according to risk.