Doctors Without Borders treat Ebola, one patient at a time

ebola Dr Stefan Kruger hugs a survivor in Sierra Leone. (Image: MSF)

Sulaiman Philip

In just the last week the World Health Organisation’s (WHO) estimate of new Ebola infections and deaths has risen. According to Doctors Without Borders (Médecins Sans Frontières (MSF)) the slow response from the WHO and western governments, and the atmosphere of fear and hysteria, has hampered its ability to slow the spread of the epidemic.

But amidst the fear and hysteria there are success stories, MSF’s Dr Stefan Kruger says. The University of Cape Town-educated medic has just returned from a month in Kailahun, the epicentre of Sierra Leone’s Ebola outbreak.

“There is one patient that I will always remember, a 70-year-old grandmother. That she survived amazed us all. She was found in her hut, close to death and brought to the hospital. Older people don’t survive usually, but she did. She thrived, helped in the hospital to feed other patients.”

Survivors develop antibodies that last at least 10 years; this immunity would make them an asset if they are allowed to return to their villages. This simple piece of information has been lost in the frenzy around the epidemic. “We took her home, embraced her in front of her family and friends. This simple act lifts the stigma of disease from survivors,” says Kruger.

ebolajohnpoole Ebola survivor Salome Karawah cares for a 10-month-old baby whose parents are being treated for Ebola. (Image: John Poole)

Medics stretched to their limits

Kailahun’s 80-bed tin-roofed Ebola complex sits in the hills on the edge of the jungle in north-east Sierra Leone. Once the bustling capital of the Kailahun District, its dirt roads are empty. Residents have left or stay indoors out of fear, and the medical personnel of Kailahun’s government hospital have either been infected or fled.

Its 220-member staff of locals and MSF personnel live in a tented compound. Wooden walkways, with tin roofs to keep them raised above the mud churned up in the rainy season, lead to the hospital, the triage tent and, in the distance, a makeshift mortuary.

“MSF is doing what it can, but we are being stretched to our limits. For me, going back isn’t a tough decision at all. In many places up to now, if MSF wasn’t there, there would be nothing – for me that’s reason enough” Kruger says.

Stopping the spread of the epidemic is not rocket science but the shortage of medical supplies, the slow mobilisation of resources and the lack of information in affected areas combine for the perfect storm. Jens Pedersen, MSF humanitarian affairs advisor, is clear-eyed and rational; “We find ourselves one or two steps behind the spread of the disease because of these factors.”

ebola1 Jens Pedersen hopes that promised aid arrives sooner than later. (Image: MSF)

Doctors Without Borders is the most visible medical presence, and often the only foreign medical team, in affected areas. The organisation is still running its malaria, cholera and HIV programmes in tandem with dealing with the outbreak; “We have heard a lot of promises from organisations like the WHO, but there is still no action on the ground,” says Pedersen.

Pedersen was based at ELWA3, MSF’s Ebola treatment centre, in Monrovia, Liberia. The 120-bed centre, the largest Ebola treatment centre in the world, is running at capacity and will need to be expanded. On arrival a patient goes through triage where a simple blood test is done. While waiting for the results the patient is quarantined for between 6 and 12 hours in a ward holding other patients.

MSF Ebola Treatment Centre small A map of the MSF’s Ebola treatment centre in Monrovia. Click to enlarge (Image: MSF)

If the test comes back positive the patient is transferred to a ward holding other confirmed Ebola patients. For most the care is palliative, but those with a chance of survival get supportive treatment as well as nutritional support and rehydration. In Monrovia the recovery rate, for a disease that still has no treatment available, is 40% of all those admitted on time.

“Why do some patients survive and others not? It would be speculation on my part but if you get treatment early you are more likely to survive. If you are young, fit and otherwise healthy you are more likely to survive. But this is speculation,” Pedersen emphasises.

Slow international aid responses hamper treatment

It is estimated that 20 000 medical personnel are needed in Sierra Leone and Liberia alone to stop the epidemic from becoming unmanageable. The United States has sent 4 000 troops to police Ebola hotspots and has promised $400-million in medical supplies. The response of Africa’s trading partners and western nations with advanced health care systems, beyond their hysterical efforts to secure their borders, has been even slower.

Ebola map The Ebola outbreak began almost simultaneously in three West African countries – Guinea, Liberia and Sierra Leone. Data from 9 October 2014. (Image: MSF)

Cuba, on the other hand, has dispatched Fidel Castro’s “army of white coats” to Sierra Leone. The 165 medical support staff, the largest contingent of medical staff from a single nation, will be followed by 296 Cuban doctors and nurses who will be stationed in Guinea and Liberia. The Cuban Medical Brigade will join MSF’s 250 staff and 3 000 local medical personnel working with Ebola patients in West Africa.

Jorge Delgado Bustillo, national coordinator of the Cuban Medical Brigade explained that since the early 60s Cuba has dispatched tens of thousands of health workers to supplement African medical structures and train doctors. “This experience is important, we are comfortable on the ground and language is not a barrier,” he said.

Despite shortages of basic medical equipment, MSF is containing the epidemic. Ebola hotspots are centred on areas with crumbling or non-existent healthcare, where things as basic as surgical gloves are in short supply. It is in towns like Kailahun, and Bo, also in Sierra Leone, where the epidemic rages that the expensive equipment used to treat single patients in Madrid and Dallas is needed.

“We don’t trust the WHO figure of 4 000 deaths, there is a lot of under-reporting out of fear,” Juli Switala, a paediatrician who has also just returned from Sierra Leone, says. Based in Bo, it was two weeks after her arrival that the first Ebola patients arrived at the hospital. Within a week admissions (of patients with other needs) had dropped to zero. The hysteria that has built up around the epidemic has hindered MSF’s ability to get out clear and effective information. “Fear follows the disease, families are hiding bodies,” she said.

ebola3 The toughest decision Dr Juli Switala has had to make is deciding to stop resuscitating children who have come into contact with Ebola patients. (Image: MSF)

Switala has had to make tough decisions in Bo. With her colleagues, they have stopped conducting Caesarean deliveries and no longer resuscitate children. “The risks of contact with body fluids was far too great. We had to make painful touch choices like that every day. The people of Bo are very tactile, they touch your face when they greeted you for example. With Ebola the whole region has become a no touch community.”

Patients are isolated from their communities and treated by staff encased in Hazmat suits so personal contact is non-existent. This precaution has affected the care that medical staff are able to give patients; simple medical procedures take two or three times longer than usual.

For Switala the 90 minutes spent in the suit every day was, strangely, the least stressful time of the day. She says her mind “was concentrated on doing things safely, being aware of what and who you touched”.

“Outside the suit you spent your time wondering who touched your phone, who broke off a piece of bread, who ate from this plate before me.”

Ebola Deaths Infographics-01A breakdown of Ebola deaths A breakdown of Ebola deaths.Click to enlarge.

Pedersen believes western hysteria means Africans are being punished for a disease they could do nothing about and did nothing to cause. He talks about a husband brought to hospital in Monrovia by taxi. It was a three-hour journey over rutted roads, his wife watching him getting sicker. The man was so weak that he needed to be carried into the hospital. His wife sat by his side waiting for MSF personnel. “He died there in the courtyard before we could get to him. Imagine the trauma that woman suffered watching her husband die. Now, imagine the response if he had died at a hospital in London instead of Monrovia.”