My cell phone alarm goes off at 7 a.m., but I am already awake. The five Americans sharing a tent with me are early risers, and my sleeping pad does not give much relief from the hard Sierra Leone dry-season earth below. A Danish member organization of International Humanitarian Partnership erected this tent city in an open field next to a now-closed Port Loko secondary school, and despite some tossing and turning in the night, I couldn’t have imagined a tent city being much more luxurious. Upright and stretching my arms, I am immediately aware of my overfull bladder and scramble to put on my sandals.
The Danish erected this expat canvas refuge in about a month’s time to accommodate the world’s dysfunctional family of disaster relief responders. Using the blueprint and experience of tent cities built amid other world crises, the Danes provided a remarkable semblance of First World life to return to each night after days full of Third World death.
I swiftly walk past the La Vida Loko Tiki Bar to relieve myself, then head toward the shower on cleanly raked gravel paths below Wi-Fi emitting towers. A hot shower is priceless on the cool December morning before the sun is high and exceeds my expectations of bucket baths based on my prior African accommodations. I am careful in my movements as there is a sharp metal edge in front of my soap where a few days ago I deposited some skin. Any opening of the skin provides an open door for Ebola, and my hands, which will be handling sweat, vomit, feces and blood in a few hours, are the most vulnerable. Any cut or scratch on my hands has to be evaluated by our clinical lead, who will decide if I am allowed to enter the Red Zone.
The mess hall hosts the many members of the disaster response family sitting at their own tables and occasionally intermingling. At one table sits GOAL, based in Ireland but staffed mainly by Brits, which runs the lab that processes all the Ebola blood tests and dead-body swabs. The vest-wearing WHO members spoon oatmeal at another table and discuss policies and procedures. CDC staffers sip coffee and enjoy Excel and numbers for breakfast. Then there’s us, Partners in Health, quickly scarfing salami and Nutella on bread to power another day of hands-on Ebola patient care at the Maforki Ebola treatment center.
My relationship with Partners in Health is young. In September 2014 I heard an NPR radio story detailing the underwhelming response of health care workers to treat the spreading Ebola epidemic, and a few nights later I applied to every organization that I could find online. Partners in Health was the first to respond. After months of uncertainty and confusion, the group got me to Boston for training at their headquarters prior to my December 2014 deployment to Sierra Leone, the new epicenter of the quickly evolving epidemic. Partners in Health (PIH) has an impressive history of bolstering some of the world’s most inept health care systems in Rwanda, Haiti and elsewhere, doing so alongside the public sector to improve each country’s medical care infrastructure. The partnership between Sierra Leone and PIH was just being arranged when the epidemic surged into the country last October. PIH, an organization that does not specialize in disaster response, was faced with the moral imperative to run directly into the fire.
Each week reinforcement PIH firefighters have been sent to Sierra Leone. The group sitting around my breakfast table was the sixth unit deployed; the six of us are to be on the ground for six weeks. Made up of three nurses, one nurse practitioner and two doctors, we come from Oregon, New Mexico, Minnesota, Missouri, Pennsylvania and New York. Our skills, experience and personalities all vary, but our presence together in Sierra Leone signifies a unique commonality. And that commonality gives me uncommon respect and trust in those I have known for only weeks.
Our driver is here, so we are off to work. The drive from tent city to our Ebola Treatment Center is three miles through the heart of Port Loko. The children spot my pale skin and wave, yelling Opato! the Timini word for “white man.” Children are everywhere, running around homes and stick-built roadside kiosks. School is not in session. The universities are closed, too. Gatherings in any form have been outlawed. So many of the joys of life are forbidden. In this soccer-crazed country I have not seen a single game being played. Not one. The ubiquitous game fields are all empty, weeds growing tall. The beloved English Premier League games are no longer showing at the cinema or on TVs at the local bars. Restaurants have limited hours or have closed completely. Travel around the country is not possible without Ebola Response passes, dispersed by the Ministry of Health, which are high in demand. Routine lockdowns forbid businesses to open in some areas, and the streets are eerily devoid of the bustling commerce that is the charm of urban Africa. No one is to have a wedding. No one is to have a funeral. To live properly, to die properly — not allowed.
We arrive at the Maforki Ebola Treatment Center, our battleground. Ebola swept into the city of Port Loko in October, and the district’s incredibly fragile health care infrastructure immediately crumbled. Patients sick with Ebola came to the district hospital, which had no ability to safely triage Ebola patients away from others. Disease spread throughout the hospital. Doctors and nurses became infected and died. Bodies were stacking up in the chaotic hospital, and President Koroma decreed that the Maforki Ebola treatment center should be opened immediately. The Red Cross hastily built Maforki by converting an abandoned school; there was no time for a well-organized center to be built. Hundreds of patients were dropped off by ambulances to be handled by the minimally trained Sierra Leonean staff. Partners in Health, with only an infant footprint in the country, vowed to stand with the Sierra Leoneans.
Out of the car and over to the day’s first hand-washing station. Chlorine has become my best friend and greatest foe. From the time you step off the airplane in Freetown you are confronted by 0.05 percent chlorine hand-washing stations. They give comfort in their potential Ebola killing power and despair in the endless cracking and eroding of my body’s only natural barrier against the virus. From the hand-washing station over to the temperature check. The no-touch thermometer is pointed at my forehead execution-style and trigger pulled. 36.6 Celsius. I take comfort in the number, well below a fever of 38.0 C. Fevers here are terrifying, and their causes many: malaria, typhoid, hepatitis, food poisoning, Lassa fever . . . Ebola. I use prophylactic medications and vaccinate against what I can — malaria, typhoid, hepatitis A — and hope to avoid the rest. My reckless tendency to chow down on street meat has to be reined in here to avoid dubious diarrhea. Allergies to the constant haze of dust can cause a curious cough. Backseat rides over horrendous roads lead to nervous nausea. Ebola leads to many symptoms, including anxiety.
Maforki is operated by the collaboration of Sierra Leonean health care workers, a team of doctors and nurses sent by the Cuban government, and Americans from Partners in Health. We all crowd together around the newly installed white boards to review the patients, who are divided into the categories of Suspect and Confirmed. Once a blood test comes back positive for a patient in Suspect Ward, they are moved into the Confirmed Ward. The community health officer, who has less than a nursing degree, presents the morning report. The health officer and Sierra Leonean nurses do a quick check on patients overnight, nothing more. Partners in Health, now numbering about 14 in total staff, does not yet have capacity to take shifts at night. No IV fluids are hung, no meds given, no bodies taken to the morgue. Stray dogs roam the wards among the living and dead, looking for a meal.
The health officer gives a one-word update on each of the 60 patients: Dry (no vomiting, diarrhea or bleeding), Wet or Dead. Those who died overnight have their piece of paper passed to the Deaths white board and await the burial team. Burials are dangerous as the bodies are highly infectious. Rural village burial traditions, including washing (just as Americans pay embalmers to do) and paying respects to the deceased, have led to many more infections and deaths, and billboards throughout the country discourage these common practices. Burial teams dressed in full personal protective equipment are called to handle all deaths reported in the country, whether at the treatment center or in individual homes. Every dead body is swabbed, and the sample is tested at the lab for Ebola.
Despite the fact that Ebola deaths have been accounting for only a small percentage of all deaths occurring in the country, every person who dies from one of the many daily dangers of life in Sierra Leone, be it malaria or childbirth or tuberculosis or trauma, has their body taken away from loved ones and buried by strangers. No mourning. No final respects. Drenched in chlorine and covered with earth to separate Ebola, present or not, from the living.
Panic attacks happen in the protective equipment. Other staff members have been held out of the Red Zone after freaking out in their suits. Because the situation becomes dangerous for everyone around, PIH now has a policy for how to deal with unconscious staff in the Red Zone.
After morning report, I look at my assignment for the day: Suspect Ward, 15 patients to see. Our team consists of two PIH staff, two Sierra Leonean nurses, and a Cuban nurse and doctor. We review what we remember about these patients from the previous days. No documentation is allowed to leave the center’s Red Zone, so record-keeping is mostly committed to memory. We make a plan for our rounds and start assembling whatever supplies are available from the storeroom. All patients receive antimalarial medicine to treat possible cases of malaria being confused with Ebola or the more dangerous scenario of malaria concomitant with Ebola. Antibiotics are given as well to treat any possible bacterial infection. Neither of these medications kills Ebola. We do not know what does.
We mix oral rehydration solution containing essential electrolytes lost through vomiting and diarrhea in 1.5 liter water bottles that have been drained by our thirsty staff. The salty-tasting solution is our first line of defense against Ebola, and all patients are encouraged to drink plenty of it. There is no cure for Ebola. No pills to take. All we can provide is supportive care, which includes trying to replace the 8 to 10 liters of fluid patients lose in diarrhea and vomit every day.
The Cubans congregate in their own well-kept nursing station, and I walk in to recruit a nurse and doctor. “_Hola_, doctor!” they say and look back at me through wide-lensed designer sunglasses. I give an elbow bump to Dr. Pepe and Nurse Sanchez. The elbow bump is the only acceptable greeting during Ebola times. Africans, in my experience, love their warm and sometimes elaborate handshakes, but now greetings feel awkward and standoffish, arms rigid at one’s sides. Avoid Body Contact is the reincarnation of the ABC rule (Abstinence, Be Faithful and Condoms) for this African health crisis, and another reason day-to-day life feels so far from natural. Dr. Pepe and Nurse Sanchez agree to meet the team in the donning room in five minutes.
It’s almost time to head into the Red Zone, and I start my ritual. After drinking water from my Nalgene bottle all morning, I supplement with some rehydrating solution. A lover of Gatorade since it was used by my mom to nurse me back to health from childhood illnesses, I chug the salty sweet fluid and give my immune system a nostalgic boost of confidence. Wristwatch off. Pockets emptied. My scrub pant legs are tucked inside long socks and my feet slip into black rubber boots that state my name in white nail polish. The final and most important step is the trip to the toilet to again empty my full bladder. There are no bathrooms where I’m going.
Our team is assembled, and we head into the donning room joined by Jack “The Eboladozer,” our energetic chlorine sprayer. The 8-by-8-foot space is dressing-room anarchy as 10 people apply layer upon layer, bumping and dancing about each other. Despite the sardine can’s rising temperature, the process provides a feeling of familiarity and calm. Size 8 gloves. Coverall suit. Size 8 gloves. N95 mask. Hood up. Apron. Face shield. Personal protective equipment on. Nothing can happen to me in here. This is my fortress.
Nothing comes in . . . nothing comes out!? I can’t breathe, oh shit, I can’t breathe. The mask and the suit and the face shield are too much on my face I can’t breathe! Just breathe faster, you’ll get more air, agghhh — I still can’t breathe! My face shield is fogging, I can’t see. I can’t see! I can’t breathe, feeling dizzy . . .
Panic attacks happen in the protective equipment. Other staff members have been held out of the Red Zone after freaking out in their suits. Because the situation becomes dangerous for everyone around, PIH now has a policy for how to deal with unconscious staff in the Red Zone.
The first time I suited up in training, the anxiety of seeing my first Ebola patient coupled with a claustrophobic sensation and quickly diminishing vision from a fogged face shield got my heart racing. My respiratory rate increased. I wondered if I could do this. Gradually I was able to talk myself into a calming mindfulness, and my heart and lungs slowed. My thoughts stopped racing. The fear was overcome. I could do this; I had to. By now, two weeks since my first time in the Red Zone, I am at ease inside my space suit.
I look into the mirror in the donning room and check to make sure my protective suit is complete. Fatmata, matron of the donning room, writes “Dr. Nick” on my apron chest with black marker and puts the current time, 10:15, on my sleeve. One hour inside is what is recommended to prevent overheating in the 90 degree Fahrenheit weather, but that is never enough time to care for our patients. I look over my team to make certain everyone has properly donned. We pick up our supplies from the staging area and head single-file past the point of no return.
We go down a long corridor and approach the open courtyard surrounded by classrooms turned Ebola wards. The outside world is kept out by bright blue tarpaulin walls on all sides of the center. This is the Suspect Ward, where patients who appear to have Ebola wait while their blood tests are pending. This area is always entered first. The flow for health care workers is unidirectional; you can never go back to Suspect from Confirmed Ward. The intent is to prevent cross-infection of suspect patients by confirmed, since not everyone at an Ebola Treatment Center has Ebola. Poorly run centers around the country have been mixing the two, without a doubt causing new infections. Patients with malaria who are taken to an Ebola center by their concerned family members are being admitted because their symptoms are indistinguishable from Ebola, and those people are then contracting the disease from the vomiting Ebola patient in the bed next to them. This is why a center specifically built to manage Ebola is ideal, but a school-turned-treatment center in the blink of an eye is what we have to work with at Maforki.
The healthier suspect patients sense the danger posed by the sicker ones and congregate in the courtyard far from the bodily fluids flowing on the floors of the classrooms/wards. We wave to them and let them know we will be with them soon, but sickest patients come first.
Enter Ward 1. I scan the room for moving chests. An 8-year-old boy is lying naked and motionless on a sheetless bed, vomit and diarrhea staining his skin. Dead. There is no sheet to cover him. He lies as a constant reminder to the other three children in the ward of what is coming.
The girls in the next two beds have pulled out their IVs overnight, a routine occurrence. The 5-year-old boy in the next bed yanked his out, too, and left a blood trail across the room to where he now lies sharing a mattress on the floor with an elderly woman too sick and weak to care for him or move away from his likely infected blood. I pick him up from a pool of blood and carry him back to his sheetless bed. His arm continues to bleed from the site of the IV, as bleeding is common in the late stages of Ebola, and I apply pressure with my hands. There is no gauze available at Maforki, six weeks after opening. There is no medical tape available. There are no wound dressings. There are no chucks (large absorbent towels) to soak up the blood. We find a large cotton ball and tie over the bleeding vessel with the strings from a yellow safety gown. Jack the Eboladozer sprays the blood off my hands, and we move to the next patient.
A thin, 35-year-old woman lies in the corner, dying. She appears to have a chronic disease, possibly HIV or tuberculosis, based on how frail she is. I was not there when she was questioned at triage and thus do not know if she was at particular risk for Ebola or was dying from another condition and brought to the center. She is naked except for a diaper, full of feces. Thick mucus runs from her nose. She is too weak to sit up, unable to talk. She needs an IV.
One of our Sierra Leonean nurses, Mariatu, says she feels confident starting the IV. Intravenous fluids have been a point of contention throughout the outbreak. Different organizations have duked it out on the pages of The New York Times over how aggressive to be with placing IVs. Any Ebola patient in the United States would get two or three IVs. Saving a patient’s life is dependent upon replacing fluid loss, and oral replacement alone is not a sufficient option. We know this. But placing IVs is dangerous. A needle stick, in which a needle exposed to Ebola blood pokes through any part of your protective suit and then through the skin, is a potential death warrant for a health care worker.
I learned on my December arrival that at least 220 health care workers in Sierra Leone have died. Ten of the 136 doctors in the country died. Yes, Sierra Leone has 136 doctors for a population of about 6 million people. That is 0.02 doctors per 1,000 people; the U.S. ratio is 2.45:1000. Many Sierra Leonean doctors are now refusing to do patient care, and who can blame them? If I were to contract Ebola, I have a PIH-provided insurance policy and agreement with the U.S. State Department to book me a direct (and costly) evacuation flight to a state-of-the-art medical facility. Only one American has died from Ebola; he had been working as a government official in Liberia. Sierra Leoneans with Ebola, doctor or not, die alongside their countrymen, with no insurance policy or access to quality care.
Mariatu holds down the frail woman’s arm, ties around a tourniquet and finds a small vein as her target. She uncaps the needle and plunges in. Once there is blood return from the catheter, she quickly pulls the needle out of the skin, and stabs it into the mattress. In any U.S. hospital, the IV catheters have retractable needles that disappear once the catheter is in place, minimizing risk. But here, in this most dangerous of environments, the deadly weapon is stabbed into the mattress, a risky practice Mariatu likely just learned in nursing school. I ask her to please remove it and place it into the cardboard needles container that I am holding.
The IV is secured with “plaster,” Sierra Leonean medical tape that must have been the first tape ever discovered after glue was spilt upon a sheet of paper. The incredibly sticky plaster is devastating to our latex gloves, and slow movements are critical to prevent the gloves from tearing. With the IV in place, we hang a bag of Lactated Ringer’s solution and give IV antibiotics. I wonder if we are doing her any good or just prolonging the woman’s death.
We tend to the other sick patients in Ward 1 and then walk outside. The Eboladozer follows us and sprays down our hands before we see the patients congregating in the courtyard. These are the patients who likely do not have Ebola but had Ebola-like symptoms that bought them a stay within this death trap. I must be sure my hands are clean from the Ebola-containing bodily fluids I was just handling. Bintu stands up from her chair in the shade and greets me. “Doctor, I want to go home! I feel strong.” She does a dance for me and smiles. I tell her, “I’m sorry, but your blood test is not back yet, and we want to make sure it is safe for you to go home.”
Her blood was taken four days ago. Blood test results take anywhere from one to five days to come back to us, and we have little insight into the cause for delays. The process is complex. All blood draws are done by a single phlebotomist, who has the most dangerous job in Sierra Leone but collects the same hazard pay as everyone else. After his draw, careful transport must be arranged. Until recently, this meant a ride into the lab in Freetown. Now, the nongovernmental organization GOAL has set up a lab in Port Loko to handle our samples. From start to finish in the lab, the test should take no more than six hours. Obtaining the results is the last hurdle, as they are often emailed and Internet access at the hospital is inconsistent at best.
Aminata had been feeling symptoms, but her baby was doing fine. She was given a choice: bring her baby inside the center with her or leave him outside. Several of her family members had died already from Ebola, and she had no one to care for him. She brought him inside with her and hoped for the best.
“Hopefully tomorrow. Do you need some more ORS?” She slumps her shoulders but nods her head, and I hand over a bottle of rehydrating solution colored with red flavoring. It is little consolation for the risk she is taking with every passing minute inside these tarpaulin walls.
We medicate the rest of the patients and talk to them briefly. Dr. Pepe and Nurse Sanchez join us after seeing some patients on their own. “Dr. Nick,” Dr. Pepe says and points to where a watch on his wrist would be. It has been one hour, and the Cubans are under strict directions from their director to exit after 60 minutes. The Cuban contingent is stationed in Pork Loko for six months, and I understand their need for pace and self-control to maintain the physical stamina to last here for half a year. I agree that the two of them should head toward the doffing station.
Before leaving Suspect Ward, we have to gather any patients whose blood test has come back positive for Ebola and take them with us through a gate to Confirmed Ward. A 24-year-old, Aminata, is positive. She came to the treatment center two days ago with her 2-month-old baby, Jiah. Aminata had been feeling symptoms, but her baby was doing fine. She was given a choice: bring her baby inside the center with her or leave him outside. Several of her family members had died already from Ebola, and she had no one to care for him. She brought him inside with her and hoped for the best.
After her first night in Ward 1, we learned she was still breastfeeding him. Ebola virus can be passed in breast milk, so we counseled her on the dangers of breastfeeding and put Jiah in a cardboard box across the room from her. Her diarrhea and fevers continued over the last two days, and I was not surprised by the positive result we received today. We go into Ward 1 to deliver the news.
“Aminata, your test came back positive for Ebola. We need to move you to another room.”
“Am I going to die?”
“No, you are going to drink ORS and stay strong for your baby.”
“Is he staying here?”
“Yes, we are still waiting on his test and we want him to stay safe and far away from the patients with Ebola. We will take care of him and feed him.”
Before walking her to Confirmed Ward, I wash my hands and go over to Jiah. He needs to get out of Ward 1. Too many people are dying in here. I pick up the cardboard box and walk to the empty Ward 7 and place it down on the steel frame of a bed. His diaper is dirty so I give it a quick change, thankful we have Pampers now. He looks up at me, rolling around on his back, and smiles. Healthy. Life.
We help Aminata out of bed and slowly escort her to a new bed in Confirmed Ward. We pass both recovering and deathly sick patients, hope and despair for this mother who has just left her only child behind. We leave her with encouraging words and step outside into the high noon sun. I can feel the sweat dripping down my back. “Mariatu, are you OK?” “Yes.” “Jack, you OK?” “Yes sir.” “Bill?” “Hanging in.” “OK, let’s get out of here.”
Time for doffing. The most dangerous place in the treatment center. Eight health care workers are standing in line to doff, as other teams have been checking on patients at the same time as us and also are exiting. There are two doffing lanes, and only one person can proceed out of the Red Zone at a time. Everyone in line looks for shade and sweats patiently.
Doffing is where health care workers get Ebola. The virus cannot be seen but is living in the fluids our hands have touched and in the vomit that sprayed onto our legs. It is there, somewhere. Each piece of our personal protective equipment must be taken off systematically in a manner that ensures any of the surfaces that might contain the virus do not come into contact with our bare skin or scrubs. Slow, mindful technique is critical. The chlorine is a crutch — studies have shown that chlorine needs to be in direct contact with the virus for more than the two minutes we use it to actually kill it, and even longer for virus contained within organic material such as vomit. This would require a dunk tank instead of our sprayer boxes and hand-washing stations. We douse ourselves in chlorine anyway, but proper doffing is the only way to guarantee safety.
First, spray down. A sprayer stands three feet away and sprays a stiff mist of 0.5 percent chlorine over almost every inch of our coverall suit. Turn, and the back side is sprayed. If the sprayer goes too high, a sting of chlorine hits the nostrils inside the face shield. Boots lifted, soles sprayed. Apron off. Front side sprayed. Spraying complete.
Next, into the chlorine foot bath. 60-second hand wash. Outer gloves off. 60-second hand wash. Face shield off, dunk in chlorine three times and place in chlorine bath. 60-second hand wash. Coverall suit unzipped down the front and taken off via an individually trademarked Ebola dance, each dancer taking great care to never touch the inside of the suit with the outside. 60- second hand wash. Face mask off. 60-second hand wash. Inner gloves off. Do not touch anything. Moonwalk out of the doffing lane, soles of boots sprayed after each step-slide by a sprayer in the Green Zone. Wash hands in weak 0.05 percent chlorine for 60 seconds. Wash hands with soap and water for 60 seconds. Sigh.
When done correctly, each person takes nearly 10 minutes to doff. This is witnessed by each person’s buddy, who one hopes will yell out reminders before a lapse. After an exhausting two hours in the protective suit, mistakes are made. Shortcuts are taken. Some were never properly trained to doff in the first place, such as the six Sierra Leonean carpenters who were thrown into protective wear to make some repairs inside the Confirmed Ward, and then came to doffing without a clue of how to safely get out. People get infected here.
After 20 minutes of waiting in line, I make it through doffing and walk back toward the Partners’ break room. Every square inch of my scrubs is saturated with sweat. I head to the water spigot and put my head underneath, rubbing my face and hair with the cool water. Boots off and into the break room, I make up a bottle of rehydrating solution and chug it down. The Danish tent city prepares a bag lunch for us, and I retrieve mine and head over to the center’s Triage Area. I make some notes on the white boards about our patients: wet/dry/IV/sicker. The staff assignments for the day are written on the board, and I am assigned to admitting for the afternoon. I will assess and admit any new patients who arrive at the center. But first, life.
At least 40 percent of our Ebola-positive patients will survive. After they are slowly nursed back to health, their blood is tested again for Ebola. Once it is found to be negative, they are no longer carrying enough of the virus to infect anyone and are safe to re-enter society. PIH staff will come to a patient in the Confirmed Ward and tell them they are ready to go home, and they smile. They leave behind any belongings they entered the center with: cell phone, money, jackets, necklaces, wallets, pictures. All of these items are burned. We take the cleared patients to the showers, where they strip naked and give us their clothes to burn. They wash their bodies thoroughly with soap and water, put on newly provided clothing and exit the center’s walls.
The discharge process takes most of the morning to arrange. By lunch time today there are five patients sitting in plastic chairs in front of the treatment center, ready to go home. They look fatigued, bewildered, relieved and scared. For the past few days or weeks they have been considered too dangerous to touch without the protection of a space suit, but today, with the flip of a switch, we tell them they are OK to live among us once again.
Many of them will return to homes now devoid of family members and possessions. Survivors were often infected while caring for loved ones who died in their home. Their homes, modest as they are, are stripped of potential Ebola-containing items. Clothes, bedding and cookware are seized by a team wearing protective suits and are burned or buried. Then there’s the question of how they will be received by their local community. Many are feared or shunned, as their neighbors are unable to understand how this Ebola patient, whom they were warned about on the radio and by posters and billboards, is now safe to welcome back home.
Our survivors for today sit near a bundle of goods PIH has procured to send them home with, including some basic cookware, bedding, clothes, large sacks of rice and other food provisions. These items cannot begin to replace the contacts in their phone, their single and favorite pair of Levis jeans or their cousin who still lies dying inside the Confirmed Ward, but it is a start.
PIH staff gather around as each survivor is awarded an official Ebola Survivor certificate to a round of applause and cheers. Each of them takes pictures with their certificate, which will serve as a necessary passport to allow acceptance back into society. They are then each given a small piece of a colorful cloth torn from a lappa, the traditional dress of Sierra Leonean women, and tie it to the small trunk of a young tree growing in front of the hospital. The Survivor Tree.
After being surrounded by sickness and death most of the day, this opportunity to cheer and laugh and give bare handshakes gives us the lift of spirit needed to continue on. These survivors have gotten past their biggest challenge, and now face a whole host of new ones. But they have life, and that is a reason to celebrate, if only for a few minutes.
Since I am on duty for admissions in the afternoon, I want to go back into the Red Zone to check on my patients before new ones start to show up. Admissions come either as walk-ups, people who feel sick and are concerned they might have Ebola, or by ambulance. The majority of patients come via the latter, as contact tracers hunt down possible patients throughout the Port Loko district.
Treating Ebola patients at the designated center does not end the epidemic. Contract tracers, surveillance officers, community health workers and public education will stop this contagion. Every patient we take care of at Maforki might have had contact with one to 20 people in their community. Contact tracers are responsible for going to these villages and doing the investigative work to see who else is at risk. Those with known exposures to bodily fluids are put into quarantine, and others are checked upon daily for 21 days after possible contact. As contact tracers and ambulances show up in small isolated villages, many community members flee out of fear that they are going to be taken to the treatment center, the place where everyone dies.
There are many pillars requiring thousands of workers to conduct an effective Ebola response. That infrastructure takes time and money and people and organization. There is not an Ebola organization — there is the WHO, UNICEF, CDC, PIH, DFID, USAID, GOAL, MSF, IMC, ICRC, etc. This is the dysfunctional family that comprises an international disaster response, or at least this one. Each organization has its own area of expertise, supply chain, standards, policy statements, protective gear, reporting mandates and accents. It is chaos.
In Port Loko, the British military has set up daily family meetings to bring some structure to the landscape of so many well-meaning international partners. Over time, this organization has resulted in a robust program of contact tracing and surveillance that has led to a downward trend of new Ebola cases within the Port Loko District. Without these efforts of so many people, many of whom have zero medical training and will never don protective suits, this epidemic will never come to an end.
At least 40 percent of our Ebola-positive patients will survive. . . . Many of them will return to homes now devoid of family members and possessions. Survivors were often infected while caring for loved ones who died in their home. Their homes, modest as they are, are stripped of potential Ebola-containing items. Clothes, bedding and cookware are seized by a team wearing protective suits and are burned or buried.
I recruit an afternoon team to go into the Red Zone to treat our patients. Mariatu agrees, although her shift ends at 4 p.m. One of her fellow nurses here at Maforki was diagnosed with Ebola a few days ago, and no one knows how she was exposed, as she did not report a breach (a tear or some doffing mistake) of her protective equipment. All the nurses are more hesitant now. Mariatu yells down to where the sprayers congregate to recruit someone for our team. No one speaks up. The sprayers have not been paid in weeks. Partners in Health is adamant about working with the Ministry of Health, to be partners with the country of Sierra Leone, and this leaves responsibilities such as paying the sprayers in the control of the government. Despite no pay in weeks, they still show up each day and risk their lives. There are rumors of a strike coming, and I would not blame them. Eventually, Mohammed volunteers to join us.
After preparing our medications, ORS bottles and other supplies, we enter the donning room. I tear open a plastic bag containing my coverall suit and put one leg through. Hundreds of coverall suits are needed each day, and our supply has run thin. There is a worldwide shortage of this expensive, necessary protective equipment. Other groups have endorsed the use of alternative suits, but Partners’ quality assurance officials are not comfortable with their safety rating. One of my co-workers wore a different suit one day and had vomit seep through it, down his scrubs.
The face shields are not available, and Fatmata yells for more to be brought. I take one with my bare hands and set it aside. I trust that this face shield, which was in the Red Zone probably one hour ago, was just soaked in properly made 0.5 percent chlorine for 30 minutes, washed with soap and water, and left in the sun to dry. I did not see any of this happen. The system for face-shield cleaning was in place when I arrived at Maforki and devised by someone else. I do not know how well the cleaners were trained or how strictly they adhere to a 30-minute soak. I put the face shield on and tighten the band around my head. Blind faith is all I have; much of my safety is entirely out of my hands.
I think about our supplies before entering the Red Zone, “Did we get some more Coartem?”
“No, it’s still out.”
Coartem is the oral medication given for malaria and should be easily attainable in Sierra Leone. We are out. Partners in Health staff started arriving here in late November to assess the needs and make requests for the supplies necessary to run the center, save lives and provide dignified care to the dying. Sheets, gowns, retractable IVs, medical tape, detachable IV tubing, morphine, blankets, rags, portable electrolyte machines: We have none of those. I do not understand what it takes to get these things from where they are sold to here, but it has been six weeks and I am enraged every time my glove gets stuck to the “plaster” we use and nearly tears open because we lack these simple items.
Back inside the Suspect Ward, we check on our patients, give afternoon meds and hang new bags of fluids. Jenny, a Partners colleague, is in Triage and yells from over the fence that we are receiving two new patients. Contact tracers, who had identified two people who were exposed to other Ebola patients and were feeling sick, had called for an ambulance to pick them up. I am on afternoon admissions duty with Bill, another Partners staffer and a palliative care nurse by trade. We walk the man and woman inside the Suspect Ward from Triage.
Bill settles the woman in Ward 3, and I stay with the man. He tells me his name, Komba, and his age, 25. He looks very weak and is certainly sick, probably positive for Ebola, but he is still walking and talking. Bill returns and takes Komba and his admission items — a bodily fluids bucket, a cup, soap, a lappa, medications — across the courtyard toward Ward 5.
I step inside Ward 3 to see another patient, and I hear Bill yelling, “Nick! Nick!” I swiftly walk across the courtyard to Ward 5, where I find Bill crouching down in his suit beside Komba, who is lying flat on the floor, just inside the doorway. “He walked in the room and just started seizing and fell over and hit his head on the floor!”
We turn him over and lift him into the nearest bed. He is post-ictal, a period of non-responsiveness after a seizure. I am not exactly sure why he seized, likely an electrolyte disturbance from extreme diarrhea and vomiting, but we do have Valium tablets that can be used to treat seizures. We turn him on his side and give the Valium rectally, then turn him back. I watch him closely for 15 seconds. No breaths. I continue to watch for a full minute, staring at his limp body. No breaths. I pick up his wrist. No pulse. He is dead. Two minutes ago, this 25-year-old man was walking and talking. Now he is dead. I have never seen anything like this.
Ambulance rides are killing people. There are no paramedics delivering lifesaving care. These are nothing more than transport vehicles. Contact tracers tell the drivers to go pick up patients in remote villages, sometimes several hours from the treatment center. Patients are told to get in the back of the ambulance, no matter how sick or weak. Drivers are told not to open the windows to make sure no bodily fluids come out. Air conditioning may or may not be working. These mobile ovens transport between one and six patients, some with active vomiting and diarrhea, over the worst pothole-riddled dirt roads imaginable. Outside temperatures are around 90 F. Patients who might not have Ebola are thrown into a washing machine with very wet Ebola patients and hope to emerge virus-free. Once the ambulance parks at the center’s gates, patients remain inside and wait for sprayers and health care workers to don full protective gear and to come open the door. Many are much sicker when they arrive than when they left their village.
Later I tell seasoned Partners’ staff about Komba. They tell me of two other patients who stepped out of the ambulance, seized and died.
I move to Ward 4, where some antibiotic injections need to be given. There is a 28-year-old female who probably doesn’t have Ebola but seems to have suffered some kind of brain damage from an infection, stroke or other event. We do not have access to the studies we need to figure out what is truly wrong with her. We examine her and she seems unable to move her left side, completely paralyzed. She will not answer questions and seems to have altered vision as well. I have an injection of Ceftriaxone antibiotic to put into her thigh muscle, as she has pulled out her IV, and a nurse holds down her right side as I prepare the injection from the left. As I poke into her thigh, her entire body jerks into motion and her left arm comes alive and grabs my syringe and needle. Clearly not paralyzed, she wrestles with me until I am finally able to pull the needle away from her hand. My heart races and my head spins.
I walk over to Ward 7. Jiah is where I left him in his cardboard box. Smiling. Healthy. Life.
From ward to ward, I roam and assist other teams and help get new patients situated. Bill and Mariatu and the Cubans and Mohammed have left the Red Zone to doff. I am not sure how long I have been inside, but the sun is getting low. Dave, age 58, a family medicine doctor like me, is admitting several children, and I go to help him. He’s been inside for quite a while as well, and we have to decide whom we will give an IV, despite the fact that all the children need them. We do not have enough time for all of them, and some will go all night without IV fluids. We pick a 7-year-old girl who looks the most dehydrated. Dave has worked in a clinic for years in the United States and has not started an IV in decades, but he bravely steps forward to help this girl. The IV is placed, but she moves and the catheter comes out. Frustrated, we move to her other arm, and I hold it as Dave tries again. The sun is setting and the lighting is terrible. The needle is adjusted but no blood flows, and Dave removes it from the catheter. While trying to put the needle back into the catheter, he squints behind his glasses and fogged face shield and misses the target but does not realize it. “Careful!” I shout, and Dave barely escapes a needle stick as he stops his hand from moving forward. “We need to get out,” I say.
We head over to the doffing area, disappointed that we could not do more for the four children just admitted. They had family members die at home from Ebola, some lost their parents, and they all likely will have positive blood tests in a few days. They need aggressive rehydration and nursing care overnight, the simple things that would keep them alive in the United States. But we have to walk away before we hurt ourselves. I have been inside for almost four hours. The 25-year-old British military medic who taught us how to don and doff our protective gear had to be flown back to England because of kidney stones he developed after repeated episodes of dehydration from staying inside the Red Zone too long. We are taught in our medical education to do everything we can for our patients, but here, that’s just not possible.
It is after 7 p.m. once I leave the Red Zone and take a shower, and I find a driver to take me back to tent city. I walk into my tent to find my five colleagues, all exhausted from the long day. We head over to the mess hall to have dinner and talk about improvements we want to make to the center. Each new PIH arrival brings fresh energy and ideas, and slowly, week by week, improvements are made in the care we are able to provide. I quietly eat my pork chop and scalloped potatoes, and listen to Kim’s idea for improving our documentation and clinical care.
“We will have binders in the break room where we can keep simple documentation to help us keep track of what each patient needs the next time we go inside the Red Zone.” I nod and marvel at her energy level and dedication; she stayed up late the night before preparing her documentation template. Kim is a 40-something ER nurse and former paramedic with a husband and 12-year-old daughter back in New Mexico. She felt the moral imperative to use the skills she had acquired throughout her career to volunteer to treat Ebola patients. She starts more IVs every day than any other staff member and has been selected to be the new clinical lead at Maforki. She has signed an extension to stay in Sierra Leone for six months, instead of six weeks. What an example to set for her daughter.
Musa hunches over his bowl of rice and fish, giggling. He was born in Sierra Leone, moved to the United States in his 20s and works as an outpatient behavioral health nurse in Philadelphia. Every night we hear him talking on the phone to his wife and four young kids that he left behind to come help his native people. He has developed a social support program for our patients, from delivering updates to family members in their native language to helping re-integrate survivors into their communities. While we were in Freetown, he welcomed us into the second home that his family has built there and provided us with a feast. I watched him hand out money to old acquaintances as he walked though his childhood neighborhood. One of the most generous souls I have ever had the pleasure to know, he has also agreed to extend his deployment in Sierra Leone to six months to continue his work.
The people on this planet are connected not only by the device now in their pockets but have always been connected by a common desire to protect and preserve one another. It has never been so easy to see. And it does not require suiting up in protective gear.
Robyn sits next to Kim and talks about the small items she wants to buy in the market to take into the Red Zone for her patients tomorrow. Back in Portland she is the single mother of a 14-year-girl. She told the emergency department where she works as a nurse that she was going to Sierra Leone to fight Ebola, and if they said no she would quit. Her passport came in time for her very first trip outside of the United States, and now here she is. Every day she works with the Sierra Leonean nurses to make them feel involved in this largely American-run operation. She encourages and trains them and keeps them safe in the Red Zone, as many are only nursing students who signed up to work in the center when their classes were canceled. Her daughter brags about her to her friends at school.
Ray sips his coffee and tells us about the trials of his day in the center. Freshly trained as a nurse practitioner, he left his wife behind in New York to use his 30-plus years of experience as a paramedic and ER nurse to treat Ebola. From India to southeast Africa to Eastern Europe to West Africa, Ray has brought his skills and dry wit to train local health care workers and provide medical care. Twenty-five years older than me, Ray cannot be held back by the space-suit perspiration records he routinely sets. I can always count on him to drink a Carlsberg with me at the end of a long day.
Quy, a Vietnamese infectious disease doctor from Minnesota via Washington and Kenya, is talking about how to reorganize the way we put suspect patients into the wards. He is notorious for getting up in the middle of the night to email lab directors and arrange meetings. He brings life out of those around him with his traveling boombox and suitcases full of things forgotten by others. He Skypes at night with his fiancée, who is currently working in Kenya — a truly global couple working to change the world. He, too, has been asked by PIH to continue to lend his expertise for a six-month deployment, and he, too, has accepted.
After dinner we retire back to our cots, and I can overhear my friends Skyping and WhatsApping with friends and family back home. The Wi-Fi connection is good enough to allow video chatting back to the United States from what was just an open field in Sierra Leone a few weeks ago. When Wi-Fi is not available, 3G data services are accessible from endless cell phone towers rising across the country. Nearly every Sierra Leonean has a cheap cell phone, and as they make a little bit of money they buy “credit” for their phones to purchase minutes and 3G data megabytes. Phone credit is a kind of currency now, and workers are even paid sometimes in the easily transferable credit. The technology advancement since I was last in sub-Saharan Africa seven years ago is striking.
From inside their mud hut homes, Sierra Leoneans are managing their Facebook profiles and sending emails. They are laughing at the same puppy memes that you are. They observe our culture and our way of life. They know how different a U.S. hospital looks from their local one. They know that Americans do not die from Ebola. They know that the United States has 100 times more doctors per citizen than Sierra Leone. Africans have entered our globalized world. Evidence of our excess, as well as their plight, is more accessible than ever before.
I am reminded of a philosophical dilemma posed by William Ramsey, the professor of my freshman year Intro to Philosophy class at Notre Dame. He presented this moral question, originally from Peter Singer: If you were to walk past a child drowning in a shallow pond on your way to class, would you feel a moral obligation to help the child at the expense of some muddy clothes and a missed class? That was an easy yes. Does the same moral imperative, he asked, apply to the millions of people around the world who are on the brink of death from various causes and could be saved with only minimal sacrifice and cost? The class went quiet, most of us internally acknowledging that we did not feel the same imperative but not understanding why.
People dying on the other side of the world have a hard time appealing to an American’s sense of moral obligation. The look on their dying faces, like the look on the drowning child’s face that appeals to the basic human emotion of empathy, is not on display before us.
Maybe Ebola patient selfies posted to Facebook from inside the walls of a treatment center will appeal to our sense of moral imperative. Maybe WhatsApp texts from nurses about to put on an inadequate protective gear will make us feel their fear. Maybe the social media silence of sprayers who have lost phone credit because they have not been paid for their heroic work will alarm us, their comfortable Instagram friends. The people on this planet are connected not only by the device now in their pockets but have always been connected by a common desire to protect and preserve one another. It has never been so easy to see. And it does not require suiting up in protective gear.
The disease of Ebola is not a Sierra Leone problem, not a West Africa problem, not an American problem. It is a human problem. And as I fall asleep tonight, in a tent with five of the most inspirational humans I have ever met, I think about what a privilege it is to be here fighting this disease with them.
Nick Stahlschmidt is a doctor of family medicine living in Saint Louis and practicing in the emergency department at Mercy Jefferson Hospital, Crystal City, Missouri.