Fieldset
"If we don't go, who will?": The Ebola workers risking their lives to save patients

When an Ebola treatment centre in the Democratic Republic of Congo is attacked and all but deserted, MSF nurse Courtney must decide whether she will go to the conflict zone to keep it open. She reveals the impact violence has on patients and staff, and introduces us to the inspiring Ebola workers who refuse to leave.

Mambasa, DRC: It was early evening and nothing over the last 24 hours had gone quite how I had expected.

The night before we were in a meeting when we overheard waves of noise in close proximity to the base. I presumed a football game had started nearby until some of the more security-savvy in our group pointed out that it sounded like a hostile crowd coming towards us.

We funnelled to the safe room and waited for things to calm down. We kept conversation light – mostly teasing each other to the soundtrack of large rocks being thrown against our metal sheeting fences and the faint sound of windows breaking.

Eventually the "all clear" was called and we slowly dispersed back to our rooms. It turns out we were not alone in having experienced unrest that night.

Caught in the conflict

The next day we awoke to news that a flurry of violence had taken place in several cities in this area of the Congo – one of the most extreme being in a town called Biakato where members of the Congolese government Ebola response team were killed in their base in the middle of the night by a rebel group.

It was sobering news for everyone involved in the Ebola response in the country.

Rumours of further unrest swirled throughout the day and it was decided that about half the team would be evacuated to a more predictable area.

I was in the process of packing my bags to go when my medical team leader pulled myself and the two other nurses aside. I think we were all expecting instructions on which tasks to work on while waiting to return to our project – but I had to stop my jaw from dropping at what came next.

They were left in a situation that could not be more challenging: an epidemic that is difficult to get ahead of at the best of times had just been rendered nearly impossible due to insecurity. I felt inspired by them...

She told us that after the fatal attacks south of us in Biakato, large numbers of medical personnel fled. The Ebola treatment centre (ETC) supported by MSF there was experiencing severe staffing shortages.

In an ETC, staffing shortages put patients, staff and the community at risk – people do not simply stop getting sick when conflict arises. The team there was making an exceptional request for medical staff in neighbouring MSF projects to help support them until replacements could be found or their staff returned.

A tough decision

This was not the conversation I was expecting. I had no question about whether I wanted to go or not. I knew immediately that I did. I just wasn’t sure I was willing to take the risk.

However, after discussions with the community, our team was reassured that MSF had not been targeted and there was no reason to have concerns about future attacks from the rebel group.

Ultimately, I accepted and 10 hours later myself and three local nurses – John, Ezekias, and Jean* – were en route to Biakato.

Nothing seemed out of ordinary about the drive – the beautiful dark green of the forest contrasting with the chocolate-covered roads and the smiles and waves of friendly faces.

However, it was evident that all was not normal when we passed the WHO handwashing station on the outskirts of Biakato. The stations are ordinarily bustling, filled with huge buckets of fresh, chlorinated water for handwashing and staff taking temperatures of passersby.

In an eerie contrast to this, the handwashing station outside of Biakato was completely empty. Staff had all either evacuated or fled the violence.

This was just a precursor to the situation that awaited me in town. Soon, I would see first-hand the consequences of insecurity for the patients and staff in an Ebola Treatment Centre.

Biakato

Arriving at the Ebola treatment centre, the mood was sombre and tense.

I walked down the windowed hallway of patients suspected but not confirmed as having Ebola and stopped at the window of a patient with a sheet pulled over their head.

A team entered the room, lowered the sheet and took a swab of the patient’s inner cheek. It came out a deep, dark brown: blood, a hallmark sign of the haemorrhagic disease.

A nurse informed me the patient came from an area where conflict and misinformation makes seeking care for Ebola difficult or impossible. Thus, people don’t usually arrive until they are critically ill. The patient had been nearly dead on arrival earlier that day.

We continued to the zone where patients with confirmed Ebola stay. Two were resting relatively unremarkably while one lay with an oxygen mask on, struggling to breathe.

The patient had also arrived in the late stages of the disease and had had a poor prognosis upon admission, but there had been a delay in administering the Ebola-specific treatment due to the security situation.

Now all the team could do is keep the patient comfortable while waiting to see if his immune system could mount a defence against the virus raging within him.

Within hours it was clear that Ebola was going to win this fight and medical staff who had dutifully cared for this patient over the last few stressful days removed his oxygen mask, lowering his eyelids and straightening his sheet over him for the last time.

The staff

The following couple of days were busy. I watched, incredibly impressed as the remaining staff pulled together and worked double shifts to ensure adequate care was provided to patients.

They were left in a situation that could not be more challenging: an epidemic that is difficult to get ahead of at the best of times had just been rendered nearly impossible due to insecurity. I felt inspired by them and wanted to write a blog post highlighting some of their stories and work.

I hoped to speak with different staff members about why they do the work they do – not only the doctors and nurses, but the staff who we hear less about, but are equally essential: the health promoters, hygienists (a combination of both cleaner and infection control workers), logistical workers and care aides.

But being both busy and an above-average procrastinator, I decided to put off some of these conversations with my colleagues until later in the week.

Under attack, again

Unfortunately, those plans were thwarted when we woke up one night to the sound of rocks being thrown at the sheet metal fences and roofs of our base. Again.

In a very disconcerting twist, we got the news that the same thing was happening at the treatment centre: the attacks were coordinated.

Intruders armed with sticks and machetes entered the health centre and the staff there were terrified. Panicking, they fled into and out of the high risk, high contamination area in an effort to protect themselves.

Within hours it was clear that Ebola was going to win this fight and medical staff who had dutifully cared for this patient over the last few stressful days removed his oxygen mask, lowering his eyelids and straightening his sheet over him for the last time.

Meanwhile, at the base, our guards responded quickly to the threat and things seemed to calm down. I tried to sleep but was awoken twice to calls from the staff at the ETC – one of our patients was becoming increasingly ill.

In spite of the danger, many of the staff remained. Some of them spending a total of five hours in personal protective equipment while trying to rig up a mini-intensive care unit.

When the sun rose, we found machete marks on our fences and a ladder that was in a position that could only suggest an intent to enter our base. 

Indirect casualties

The news got worse once we arrived at the ETC – the critically ill patient had died that morning. This, at least, we had expected given the updates in the night.

We were all quite surprised (and distraught to say the least) to find that two very sick young children had also passed away in the paediatric department overnight. The nurses there had (understandably) fled when the ETC was threatened and these children died due to a simple of lack of medical care while hospitalized.

In any conflict, there are direct casualties and indirect casualties.

The direct casualties being the three men killed by a rebel group (may they rest in peace). But lesser-known and unlikely to make the news are those who die in a more indirect manner – those who are infected with Ebola or other illnesses due to lack of access to vaccines, treatment, lab testing and medication, and a lack of staff and supplies.

We have not yet seen the ripple effects of the days spent with no handwashing stations and the inability to provide contact tracing or follow up for contacts of known Ebola patients. But we will.

For Ebola workers and sick people considering whether a health structure is a safe option for themselves or their beloved family members, the message is clear: the ETC cannot protect them.

"It's not safe for you here"

In my last week working in DRC, the violence spread north, closer to the town where I am currently based (Mambasa, DRC).

Our first warning of this attack to the south of us was a doctor from the government response team arriving at the health centre to evacuate his staff. His message was blunt and in spite of the ever-present rumours and threats, still startled me: "It’s not safe for you here. You need to leave right now."

In spite of this, many national and international staff stay and continue to work in these insecure environments. This is who they are and why they do it.


The health promoter

Esperence plays a key role in Ebola prevention and care. As a health promoter, she acts as a liaison between the patient and the health care team, explaining complex medical messages in simple and accessible language and terms.

Being admitted to an ETC can be a scary experience with foreign, rigid procedures to follow. She calms the fears of the patients and works with the families so that they understand what is going on with their loved ones and feel supported.

This work is important to her because she has experienced what it is like to have a relative with Ebola. At the start of the current epidemic, Esperence lost five family members in two weeks to the disease.

"This is a disease that will kill an entire family in a week," she says. Esperence stays and works even though she is afraid at times because she does not want patients and family to suffer like her family did.

The water and sanitation specialists

The unsung heroes of the fight against Ebola are truly those working in water and sanitation, and here are two absolute rock stars in this field.

Meet Eddy and Esdras, two watsan supervisors who have lived and worked in practically every Ebola hotspot and some of the most insecure contexts of this epidemic. They tell me that there is a huge difference when comparing the Ebola response in an insecure versus a secure area:

"When there is no conflict, people come to the ETC readily – they understand the importance and are not afraid. They understand that if they seek treatment they will receive it and be safe.

"When there is insecurity it makes people too afraid to come. It also affects us, but not necessarily because we are afraid – we aren’t – we have gotten used to it. We follow the security rules and try to be as safe as possible.

"But it gets tiring to have your freedom and ability to live your life curtailed to such a huge degree over long periods of time. Our families worry. They are in a safe part of the country but they always call the moment they hear something bad has happened. Even if they know we are hours away."

When I asked them if, from their perspective, insecurity affects the provision of supplies and personal protective equipment from reaching their destination, they chuckle at me and respond with a resounding "no".

"MSF is pretty good with logistics in conflict areas you know, Courtney."

(Shout out to all the logisticians of MSF Ebola response who are awesome at getting us the supplies we need, seemingly out of thin air at times)

When I asked them why they do this work even though it is busy, stressful and insecure they responded: “We do this type of work and make these sacrifices because these are our people and our communities at risk and suffering.

"We know that it takes training and a lot of experience to do the work we do well, and we can offer that.  If we don’t help, who will?”  

The nurses

I met John and Ezekias in a slightly calmer locale when working in a place called Mayuano about four hours north of Biakato. When I saw them hop into the truck to head south I was super happy to see and work with them again.

Nurses in an Ebola context do all the things nurses elsewhere do but in full personal protection equipment (PPE, an impermeable suit lacking any air that I like to jokingly refer to as a human-sized condom).

It helps keep us safe but due to the extreme heat, we have limited time to provide all the care necessary for patients (one hour maximum in the "high risk" zone). The nurses become good at providing both solid nursing care and a human touch to their patients in a very efficient manner.

For those of you who are healthcare workers: imagine trying to insert an IV on a dehydrated infant with two pairs of gloves on in a shady room, while wearing fogged up goggles –these guys are pros!

When I asked them why they choose to leave a relatively calm area to work in a security hotspot their response was simple: "They needed help so we went."

The survivors

 

Imagine five of your 12 beds in your Ebola treatment centre are filled with sick, crying, frightened children under two years old, who are separated from their parents. Sounds like a nightmare, right? Honestly, it is.

The unfortunate reality of Ebola is that children often pass it to their parents and vice versa. Thus, if we suspect Ebola in a child, we have to place them in isolation away from their family. This always heart-wrenching experience is made a little more tolerable for all parties involved with the help of "gardes malades".

People who have survived Ebola, known as gardes malades, are thought to have an immunity to the disease, so they don’t have to wear full PPE. Whereas nurses and doctors can only spend a very limited time in the high-risk zone due to their PPE, garde malades can stay all day.

They soothe, comfort, feed and clean these little babes and any other patient needing more support, and are absolutely essential in the running of an ETC.

When I asked one garde malade why she stayed and worked in spite of the unrest, her response was perhaps the most universal of all for people living in an area of frequent conflict: "This is my home and this is how I provide for my family. If I don’t work, we don’t eat."

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