/ 24 February 2016

A doctor reflects on his time spent fighting Ebola

MSF staff in protective gear at work in Kailahun.
MSF staff in protective gear at work in Kailahun.

Months of talking and more than a year of reflecting, and finally on January 6 we went into the Magburaka government hospital to work alongside Sierra Leone’s ministry of health, supporting the life-saving activities of the clinical teams in maternity and paediatrics.

There are many events I will remember from that first weekend: the first of three newborn babies to present with neonatal tetanus – watching his face scrunch up in pain as his muscles contracted, our presence enabling the hospital to deliver medicine, analgesia and care for him. In maternity the ambulances kept coming, sometimes two patients squeezed in the back together.

There were women with ruptured uteruses, one needing an emergency hysterectomy, a teenager in labour for days who subsequently developed a fistula, and a woman who came with a massive placental abruption needing emergency surgery despite huge blood loss. I will remember, too, that no woman died and no baby survived.

That first weekend will also stay in our memories for the patient we didn’t see. A 22-year-old woman came to outpatients. She presented with vague symptoms; she was seen by health ministry staff and was sent for tests, and went home.

She died three days later at a family home in Magburaka and then had a traditional burial. As with all deaths in the country, she was swabbed for Ebola before burial.

On the Thursday evening we gathered for a team meeting – one week into the project and the mood was good. We made a brief toast as the World Health Organisation was finally due to announce that the Ebola outbreak was over.

Health workers carry the body of an Ebola victim for burial in Freetown, Sierra Leone. (Baz Ratner, Reuters)

We first heard rumours that the 22-year-old woman’s swab was positive about 10 minutes later.

When Ebola first visited in 2014, no one knew what to expect. Paranoia was rife and the death toll soared. At our previous hospital we tried to withstand the force of the disease and find ways to keep going, but ultimately it was stronger than us. Closing the maternal and child health project back then was a painful decision but the safest one, given the uncontrolled situation.

That experience kept many of us returning during the outbreak, and pushing for the need to create a project that could withstand another. That objective was now being tested less than a week after opening.

On the Friday, a group of us got up and quietly left for the hospital in the dark. The confirmation had not yet come, but rumours were all around the town.

We made our way from ward to ward, checking on every patient. We talked to all the staff, ensuring there was sufficient protective equipment, hand-washing and observations for any worrying signs.

We retraced the flow of patients through the hospital and put plans in place for isolation facilities. Pregnant women and children are especially challenging groups in an Ebola outbreak. Separate isolation areas, thought out according to different needs, were quickly set up. Before the sun had risen, before the world was told, we were putting up defences and getting ready to fight.

Once a case of Ebola is confirmed, the definition for suspecting the disease changes. If not carefully applied, with scrutiny of patients and their symptoms, it can result in the unnecessary isolation of many sick (and easily treatable) conditions. We carefully question each patient and use universal precautions for everyone. But this takes time and can lead to delays in treatment.

When the official announcement finally came, it was no surprise. I had assumed our fledgling project would suffer and that new staff would not come to work, but I was wrong. Everyone came, and the team has stood taller and stronger than I would have ever dared to expect.

The decision to isolate a patient carries huge responsibility. On the Saturday, a nine-year-old girl was brought in by her mother with a high fever, weakness and difficulty breathing.

The girl was visibly very sick, probably with severe malaria, and in her critical condition isolating her – treating her in a tent and only while wearing protective suits – would limit the care she could receive.

If we did not isolate her, though, we would be risking a very precarious situation. The mother sat across the orange plastic fence from us with her daughter in her lap. Lovingly supporting her head, she looked at us, the defendant facing the judge and jury. We searched for a way to justify the decision, but we were cornered. We agreed to isolate her and begin treatment.

As we prepared to isolate, the girl’s breathing slowed, then stopped. We could not touch her; we could only throw a cloth over for her mother to wrap her daughter’s body as she murmured and sobbed. The body had to be treated as if Ebola-positive and the whole area decontaminated. The posthumous test was negative.

People gather in Freetown to pray for Ebola victims. (Florian Plaucheur, AFP)

Ebola is a cruel disease, not only for the illness it causes but for the collateral damage it forces us to be part of and bear witness to.

On the Wednesday, news came that a woman who had cared for the person with Ebola was going to be sent to us for assessment. The challenge would be making sure she could be assessed and cared for, while maintaining normal hospital services. 

We managed to admit her into isolation discreetly. There are some characteristics to Ebola infection — a certain way of moving, a look in the eyes and lethargy. They can be subtle, but they are also recognisable. The test was taken, but we already knew what the result would be.

The concept of the project was now being truly tested: we were isolating the only suspected Ebola case in West Africa, and simultaneously running a busy general healthcare facility. 

A woman with twins was in labour, but they were not coming. The twins were “locked” together, a rare complication that put all three lives at risk. We rapidly got her to theatre and delivered the babies; all three of them are now safely home. In between managing the screening and isolation, we continued to see ambulance after ambulance arrive.  

The woman suspected of having Ebola tested positive, so we mobilised counsellors to get the news to her before the local gossip spread. We then transferred her to the referral centre in Freetown.  

We were isolating and testing for Ebola while a stone’s throw away we continued to perform emergency surgery and resuscitate mothers and babies in the country with the world’s highest mortality figures. 

And, despite being the last place to treat an Ebola patient, we are seeing an increase in people coming for care. More pregnant women are coming to wait for a safe delivery than ever before — word has got out that the Magburaka hospital offers quality care, and we (a partnership between the health ministry and Médecins Sans Frontières) do so with pride.  

On the Friday night, three of those waiting went into labour. One of them, a 25-year-old in her seventh pregnancy, had no living children. She cried with fear, afraid to push in case history repeated itself. We supported her, gently coaxing her through. The baby came with the cord tightly round the neck; calmly and quietly we helped him breathe. The woman then had a massive haemorrhage. 

We got her to the operating theatre, eventually managing to stop the bleeding.  If there is any symbol of those first weeks it is that woman looking contentedly at her healthy boy, being cared for in the proud arms of his grandmother. 

We have seen what Ebola can do, and we are working to prevent it disrupting the vital services we are supporting the hospital to provide. There was no emergency team, no influx of international staff or trucks of supplies. We managed with what we have and who we have. 

Ebola came and showed its ugly face again, but I am glad it came to where we are. Together, national and international, we have stood firm. One woman died from Ebola in the past month, but many lives were saved. —   © Guardian News & Media 2016 

Benjamin Black is an obstetrician and gynaecologist for Médecins Sans Frontières.