Ebola diaries: Fighting an uphill battle

Rob Fowler

Dr Rob Fowler is a Canadian critical care physician from Toronto who was recruited by WHO in August 2013 to work with the Pandemic and Epidemic Diseases clinical team. When the Ebola outbreak was confirmed in late March 2014, Rob was part of the first clinical response team to deploy to Guinea. In the months to follow, Rob worked at an Ebola treatment centre, focusing on treating dehydration, organ dysfunction and shock to drive down mortality rates.

Conakry, Guinea, 2014: Before entering the hospital, people wash their hands with a solution of chlorine and water to avoid spreading the Ebola virus
WHO/M.A. Heine

"I was in Geneva at WHO, when the first case of Ebola was confirmed in Guinea. From that point I knew that in a few days I would likely be part of the first WHO team on the ground.

My first entry into the ward was at Kipé Hospital in Conakry where there were a number of Ebola patients – most were health care workers. Other patients had already left the hospital in fear. There was only one nurse in the ward at a time and few doctors were left, uninfected. No one had the luxury of prior infection prevention and control training for Ebola and the result was devastating. So my first reaction when entering the hospital was grave concern and no small amount of fear that anybody working in the ward was at risk.

Those first weeks were a continuous cycle of long hours of clinical care in the cobbled together Ebola Treatment Unit on the grounds of Donka Hospital, while simultaneously providing clinical advice at WHO Ebola response coordination meetings each morning.

Few beds, treatments, doctors or nurses

The early days in Conakry, for me, were the most challenging because of the lack of resources – lack of beds, medication and personnel. When I first arrived there were about four Guinean doctors and nurses and four international physicians and nurses caring for patients in the capital. There were too few clinicians to provide medical care to infected patients.

Many of the national staff, without sufficient prior infection prevention and control experience, had become infected and this decimated the clinical workforce. We had over 100 patients and some days, only a couple of doctors and a couple of nurses. It is so very hard in that environment where staff is getting sick.

There were so many challenges with this outbreak. The affected countries had not previously experienced Ebola before therefore the basic procedures in handling an Ebola outbreak were not in place. In prior years, there were periods of civil unrest, government instability, and health care infrastructure challenges that lead to an inability to meet the basic public health and acute health needs of the population. The Ministries of Health and national healthcare workers do their best, but they are working in a system with insufficient support.

Rob Fowler, a critical care physician from Canada, working in West Africa on Ebola outbreak 2014
WHO/S. Gborie

The importance of prior infection prevention and control training and expertise in keeping healthcare workers, patients and the public safe -- this cannot be over-emphasized in my mind. So, any outbreak in this environment was going to be a tough one.

This is also the first time that Ebola hit urban centres and has travelled from one location to another with so much ease. Usually the outbreak is geographically distinct, isolated and often in a remote area. Soon, there were not just one, but many, outbreaks; many fronts to fight simultaneously.

Setting the tone for good clinical care

The clinical care of patients is a tiny piece of the response. However, I think it is a very, very important one. When mortality is very high, and Ebola treatment centres function more to isolate people than to provide care to patients, the population is reluctant to voluntarily seek care due to fear.

Over the following month, I think this team helped to set the tone for a style of clinical care – early aggressive rehydration, antibiotic and antimalarial treatments, and point-of-care laboratory directed treatment of metabolic and electrolyte abnormalities that has generally been adopted across West Africa.

It is not so common for WHO to send in clinicians – doctors and nurses - to assist Ministries of Health to provide direct clinical care; however, during this start of the outbreak, the need was too great and assisting with the care of patients became one of our priorities – out of necessity."

By December 2014, Rob had deployed four more times starting in Guinea in March, Sierra Leone in July, Liberia in September, and Sierra Leone again in December.