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Dr. Gillian Seton continues to work at Cooper Hospital in Liberia as Ebola spreads throughout West Africa. Here she shares her personal update on the situation. The hospital, the people of Liberia, the trials she is enduring. Through it all, she and the staff at Cooper are remaining strong and dedicated to the work they have set out to do. Read more here.
September 19, 2014
It doesn’t jump out suddenly; it comes in small steps so that you before you realize you’re in trouble, it has surrounded you, found all of your weaknesses, and had plenty of time to grow into your worst nightmare.
Ebola outbreak. Hemorrhagic virus. 50-90% mortality. Spread by contact with body fluids. It isn’t quite match criteria for the zombie apocalypse, but it has come very close.
How do you avoid contracting this deadly virus? Simple: don’t touch any sick people. Only, this isn’t a simple precaution for West Africa, which is quite simply the worst set-up for continued spread, misinformation, fear, violence, and death. Family members take care of family, which translates into cleaning up vomit and diarrhea, bathing the sick person, carrying them wherever they need to go, and often, cleaning the body for embalming and/or burial. Add entrenched burial rituals, ignorance and a very strong network of gossip (it takes approximately 10 minutes for news to spread from one end of the city to the other). Add distrust of the government and any authority figures. Add ill-prepared medical clinics and hospitals which have never before practiced even simple universal precautions due to lack of gloves, trash bags, waste management principles, etc. Add in health care workers who often care for patients out of their homes or make house calls.
Now add rumors of government officials stealing people so that they can use their blood in spiritualistic rituals for upcoming elections. Add rumors of kidneys being stolen for black market sales for transplants (regardless of the fact that there are no transplant surgeons, equipment, or knowledge of how to preserve such kidneys). Add to this massive distrust by keeping Ebola-contaminated bodies away from families for their own protection. This is why we started hearing about riots and violence against hospitals.
Now add on rumors of Ebola spreading through well water and someone then poisoning the wells with arsenic. Even the trained personnel who service and test these wells are not allowed near them.
Now add a death rate of between 50-100 people PER week, many in rural towns and distant cities where there is little or no health care currently available. Add people who flee from one village to their families in the cities, already exposed but without symptoms yet. Add on the reluctance to admit to anyone in the hospitals or the Ministry of Health that you have recently been with someone with Ebola. Sum of all evils = the virus jumps from family member to family member, parent to child, from patient to ill-equipped health care workers, and from there to the larger hospitals and to the next and to the next…
I came to Liberia to work in a small mission hospital in Monrovia, the capital city, in February of 2014. I had finished my general surgery training a few months prior and fulfilled my lifelong ambition to work in developing countries to provide needed surgical and emergency care. I was greeted by an amazing administration and welcoming staff at SDA Cooper Hospital, a small hospital of 30-50 beds. I quickly grew to appreciate many things about Liberia. Although, I came knowing that I would face certain dangers, disappointments, and frustration at the lack of resources, I never once imagined that I would face an outbreak of a deadly hemorrhagic virus.
How do people here view the outbreak? In the beginning, there was absolute denial about the existence of Ebola for the first few months, even among educated and well-traveled Liberians. Although its existence is more accepted now, there is a great deal of misinformation and lack of understanding in how the virus acts and how it spreads. Also, people STILL prefer to pretend that they don’t have Ebola; whole families are wiped out because they would rather believe that a poison or a curse is responsible for all the deaths instead of Ebola. Given the two most deadly locations is in the home of someone with Ebola and a hospital, people are avoiding hospitals until they are within hours of death. This complicates treatment of malaria and severe anemia, stroke and severe hypertension, trauma and even OB emergencies.
We are routinely seeing patients at our door who have tried 3-4 other hospitals and been turned away due to no staff or due to concerning symptoms. Unfortunately, the Ebola virus shares symptoms with malaria, sepsis, typhoid, and every other virus in this region. It’s difficult to separate those at risk due to previous exposure from those who just have one of the “normal” diseases. Due to fear of being turned away, family members ROUTINELY lie about symptoms. They claim treatment at another clinic but do not tell the whole picture, thereby delaying testing and treatment and potentially infecting another group of people (ie, us).
E.L.W.A. hospital was one of the few hospitals with foresight and the connections to be prepared. At the first sign of the outbreak, they requested supplies and additional training. Their hospital is small, but the campus is extensive and so they built a separate temporary building with holding rooms and isolation units in order to treat patients. Precautions were taken with every patient who approached. However, even the maximal precautions weren’t enough to protect their staff. Now MSF (Doctors without Borders) has provided much needed extension to this Ebola center with 125 beds that opened around August 20, followed by another 100 beds within a week, and every few days more tents are going up. Only, they fill faster than the tests arise or staff can be found. People are being turned away and sent home routinely.
What recourse then, except for these patients to go home and die? And infect the rest of the family? Or seek treatment at one of the few remaining hospitals/clinics that are open? Can you understand the desperation?
The nightmare then gets much worse. Despite promises from the Ministry of Health, suspicious bodies (those who died without known cause, especially after contact with Ebola) are not picked up and appropriately buried. Bodies in the community wait for days before pick-up and there aren’t enough vehicles and teams for appropriate burial. Considering the risk of exposure from retained body fluids, this is also a significant factor to the rapid and never ending spread of the virus. This doesn’t even take into account the difficulty of cultural expectations in burial rights, Muslim practices of washing the body and burial within 24 hours, and the burial teams facing danger of violent reactions in the smaller cities and villages. Cremation is now recommended/demanded, but there aren’t enough facilities to make this practical on a large scale. Even burial is becoming difficult: how to dispose of so many bodies rapidly? Most burials are in cement tombs since the water table is so high (lets not even get into the question of water contamination from dead bodies to the Monrovia community which relies on wells or the rural communities which have a choice of rivers or wells…).
Isolation and quarantine seem like a good idea, even if you condemn otherwise healthy people to stay in an exposed area. How long do we let this continue until we make a few sacrifices for the larger good? How would you feel if you were the one left behind? Liberians do not have a good track record for doing as told; indeed, even if there were successful roadblocks around high incidence areas/cities (as have been attempted), people have no trouble walking through the jungle on foot or using violence to get outside of the quarantine. Also, there isn’t a large enough force to ensure such quarantine in the larger affected areas, let alone the small pockets of outbreak. How do you lock down a community when people live day-to-day, no refrigeration, no savings accounts, community water sources, etc.?
The country is in a state of emergency: more police and armed forces are visible, even the police are now escorting vehicles with dead bodies to designated locations (although where that might be and what happens there, I do not know). Dissent among the people and media is being strongly discouraged; for right or wrong, such dissent is usually based on wickedly erroneous information and has lead to significant violence, so I can understand a heavy-handed policy. It just goes to illustrate how serious this crisis has become. Politics are out of control, the government doesn’t have enough standing among the community to make effective protocols, and no experience in practical implementation.
There is now a general belief that the virus cannot be controlled for many months yet. At first is was several months, then 6-9 months, and I just saw projections of between 20,000-100,000 cases and spread to something like 45 countries before this virus runs out of new contacts.
Ebola teams and regular small clinics need gloves, gowns, medications, IV supplies, etc just to handle very basic care. In the past, they didn’t routinely receive these things, so how is it going to happen now? With the arrival of major players such as MSF, WHO, CDC, we are all hoping they can provide the logistical support and knowledge to get supplies into the country and distributed in a regular/fair manner (and somehow guard against corruption, outright theft, and misuse due to misunderstanding). This job, however, is so very complicated and they are not too hopeful of human efforts to halt the spread of the virus. One doctor expressed his belief that we’ll get to the point of handing out home “kits” for families to use while caring for infected loved ones. What a sad nightmare; as a trained physician, I’d find it difficult to adequately care of an Ebola case, let alone the grandmother without any formal education.
This is where we stand now.
We wait and work on baited breath here at SDA Cooper. Although there are no local suppliers that can meet current demands, extra supplies and random but very useful kits are being donated to us. Loma Linda University in California is a regular supporter; Adventist Health International has been helping the hospital system develop to self-sufficiency and quality care for several years and now have been sending us needed supplies regularly at great cost. ADRA Liberia and International divisions have donated very useful supplies and pledged further support. The Seventh-day Adventist Church global office has also been supportive with supplies and funds since we are operating now far outside our budget and patients are frequently unable to pay. It is taking the massive resources of these supporting groups to keep us open.
We had a visit from the President, Ellen Johnson-Sirleaf, on August 24 as she had heard about a trauma patient we treated. She has pledged her support for our hospital, which we sorely need. Within the following 48 hours, by August 26, we were out of fuel and nearly to the point of caring for patients by flashlight (if lucky enough to have batteries) and candles. It isn’t necessarily the lack of funds (American dollars) due to the support of our friends, but it’s the DELIVERY of the fuel from the major company, their employees continuing work, and their professional honesty not to embezzle funds. But just in time, one of the executives of a major fuel company dropped by on the request of the president and donated some 500 gallons of fuel.
President Johnson-Sirleaf, or “Ellen” as I hear her regularly called by Liberians, returned September 8th to check on us and the patient (who was readmitted for political reasons/protection, rather than medical necessity). Pictures attached are of President Ellen and our business administrator, Mr. Wennie, and some of our hospital staff.
Now, on to a few bright notes: the hospital routinely rings with the healthy cries of newborns, our first very complicated trauma patient is doing well, and our staff continues to come to work even though we are hording our last isolation gowns and triaging our patients outside the hospital in the rain. A group called Global Medic, in partnership with ADRA, have donated large tents that we are setting up outside so that patients aren’t soaked while waiting and eventually we can triage everyone outside. We have yet to have any staff contract the virus, although many have friends and a few family members who have died of the disease. And we have had a few patients who were later confirmed to have Ebola. So we hope and pray that we stay healthy and that we can provide some hope to the few patients who reach us in time for our meager capabilities to treat. Our death rate has skyrocketed as we try to treat a mixture of late stage disease, but we are growing stronger as a hospital. Our staff are doing much better with universal precautions and continue to make sure I smile every day. One of the best features about Liberians is that they frequently express their gratitude. “Thank you, doc” and “thank you mama” (address for every woman over the age of 20: mama, missy, auntie, woman) follows me through the day, regardless of the whether or not I’ve actually been able to help.
Personally, I’m exhausted. But, it helps to work with such a dedicated staff and administration. It helps to have an additional physician volunteer, Dr. James Appel, who has worked in Chad for the past 10 years, was able come to add his knowledge and skill to our work-load. It helps to see patients improve. It helps to only take on those challenges that I can help, and leave the rest to someone else. It helps to know we have a great deal of support from around the world. And we pray that this outbreak has an end date in 2014.
Who knows if 3000 troops and $500 million dollars will actually mean practical help? We’ll see…