Fighting Ebola from day one
Interview with Rob Fowler, a critical care physician from Canada, who worked in West Africa since the first confirmed cases of Ebola
Getting the epidemiology right, contact tracing, social mobilization, infection prevention and control are what will play the biggest role in stopping the Ebola outbreak
Dr Rob Fowler, a Canadian critical care physician, landed in Conakry, Guinea, the last week of March 2014, focussed and eager to get to work. He joined his WHO colleague Dr Tom Fletcher, an infectious diseases expert from the United Kingdom. Both had been recruited by WHO/Geneva to work with the WHO Pandemic and Epidemic Diseases clinical team, led by by Dr Nikki Shindo.
In Geneva, Rob and Tom shared office, and long before the onset of this outbreak, they had ruminated over the high mortality rate in Ebola outbreaks, and how a clinical response team focused on treating the syndrome of Ebola – dehydration, organ dysfunction and shock – might help to drive this mortality down. In the days that followed, Rob was to immerse himself in a WHO-established and MSF-run Ebola treatment centre to treat the Guinean capital’s first confirmed cases of Ebola.
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.
While establishing effective coordination was clearly important, it was obvious that Rob wanted to return to the ever-growing number of patients as soon as possible. This has been a recurrent theme of the outbreak – an unprecedented, overwhelming and relentless ongoing need.
In late December 2014, he was on his 4th mission to West Africa. In a newly open treatment centre near Freetown, Sierra Leone, he was explaining to new staff how to put on and take off personal protective equipment (PPE). This is when he was interviewed.
Q: You said once you took a sabbatical year and came to Geneva to work?
Rob: I am a clinical care physician from the University of Toronto but, in August 2013, I started a sabbatical year at the WHO in Geneva. My intended focus was to help better prepare WHO’s response to outbreaks, epidemics and pandemics.
We specifically worked on how to better describe what was happening on the ground so we could learn in real time what the needs were and identify the gaps. The goal was to create a platform that would describe patients that are in outbreaks and test interventions that might improve outcomes.
Between August 2013 and March 2014 we worked on that agenda for Avian influenza (H7N9) and Middle East Respiratory Syndrome coronavirus. These are important pathogens that have caused illness and death in China and the Gulf States. However, with the recognized start of the Ebola outbreak at the end of March, everything changed. Tom and I were in Geneva at WHO, when the first case of Ebola was confirmed in Guinea. We looked at each other and knew that in a few days we’d likely be part of the first WHO team on the ground.
Ebola is a very different clinical syndrome – it is predominantly a severe febrile gastrointestinal illness. Infected people experience diarrhoea, vomiting and, usually, very little respiratory illness. Whereas mechanical ventilators and intensive care units are frequently necessary to treat respiratory failure among people with H7N9 and MERS-CoV, the complications of Ebola can be treated with intravenous fluids and rather simple supportive care – things that we can provide in West Africa.
Q: How did you feel when you first entered the ward in Guinea
Rob: 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.
In the early days of the outbreak there were about 4 Guinean doctors and nurses and 4 international physicians and nurses caring for patients in the capital. 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. I give so much credit to MSF for their early response and ability to operationalize treatment units.
"The world cannot be complacent about communicable diseases and health disparities focused in one part of the globe. First, it is globally immoral. Second, we are too interconnected. There is no “your problem” in 2015 – global health is our collective responsibility."
Rob Fowler, a critical care physician, Canada
Q: What did it mean for you to be a part of this first team?
Rob: Ebola for me – and for other people – conjures up more concern and to be sure, some fear. So for me, that leads to apprehension and caution, but not excitement.
Having been in Toronto at the onset of SARS and admitting some of the first patients and taking care of colleagues…going through that experience, it was easier to mentally prepare for entering into an outbreak where the outcomes are uncertain and the mortalities are potentially high. New and emerging infections are anxiety-provoking; however, if you are a clinician and you find yourself in those situations, it is what you do.
Q: As a doctor, normally you develop a relationship with your patients, here that wasn’t really possible. Was it something that was missing?
Rob: Initially it was missing. I remember the first time going into the ward in full PPE and we were plain and faceless. The PPE that we had used was a much lighter version of what was starting to be used in West Africa, although with the same protection of your mucus membranes – eyes, nose and mouth, where Ebola typically gains entry.
So it did allow people to see more of our faces which I think allowed the patients to connect with us a little more quickly. We would write our names on our boots and aprons saying that we were OMS/WHO and say what our first name was: “Dr. Rob – OMS or Dr. Tom – WHO”.
In some places we could speak to patients across a barrier or a fence, without PPE, and that helped to create a bond that carried back into the treatment facility, where patients could not see us as well.
Q: You went first to Guinea, the next location was Sierra Leone
Rob: I went to Guinea in March-April, Sierra Leone in July-August, Liberia in September and Sierra Leone again in December.
Both in Guinea and in Sierra Leone we were in situations where there were too few clinicians to provide medical care to infected patients. MSF has been the predominantly humanitarian medical organization providing assistance to countries and care to patients with Ebola for the past decade but with this outbreak, despite terrific work, even MSF was overstretched.
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 outbreak, especially in the first months the need was too great and assisting with the care of patients became one of our priorities – out of necessity.
Since August, the international foreign medical team community has really stepped up and there are now scores of organizations helping with Ebola care across West Africa for the first time. The WHO clinical team is now leading training for incoming teams and supporting existing teams in their Ebola treatment centres.
Q: How has it felt to be one of relatively few WHO clinicians during this outbreak?
Rob: The clinical response is just one small part of outbreak activities, and I recognize the clinical response is never going to be the most influential aspect in stopping the outbreak. Getting the epidemiology right, contact tracing, social mobilization, infection prevention and control are what will play the biggest role in stopping the outbreak.
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.
This is a big problem for both the patient, but also for others that will become infected from contact with that patient, should they not be in a treatment centre. The Ebola clinical syndrome can be managed with available treatments – oral and IV fluids, electrolyte monitoring and replacement, and antibiotics and antimalarials for co-existing illness. With enough health care workers to spend time with patients, we can deliver excellent supportive care and drive down mortality.
It has been the clinical team’s goal to advocate for improving individual patient care. Outcomes are much better if we do what we are able to do. It has been an honour to serve alongside the dozens of WHO clinicians – country and international staff - who have deployed so many times across West Africa.
Q: What was the most challenging part of these 9 months?
Rob: The early days in Conakry, for me, were the most challenging because of the lack of resources – lack of beds, medication and personnel.
In Sierra Leone however, in the middle of the year – 5 months into the outbreak – it was also very hard. While we had beds and medications, we had too few clinicians to treat 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.
Q: Why did it get so bad?
Rob: There are 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.
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.
Also, over 2013-2014 there were so many other, competing international health priorities - Avian influenza in China, MERS-CoV in the Gulf, and disastrous interruptions in public and acute healthcare in Central African Republic, South Sudan and Syria. Public attention was divided and organizations like WHO were stretched to be sure.
We all look back, knowing the size of the eventual outbreak and the challenges at the time, and wish we could have improved our collective capacity for outbreak response. However, it is hard to say in truth and honesty that things could have been shut down with one specific change. It was a range of factors in both West Africa and indeed around the globe that conspired against the quick and deep response that we wanted to provide.
Q: What did you learn that you would really take from this experience?
- The core components of outbreak response are so very important – epidemiology, contact tracing, social mobilization.
- Isolation and treatment of those infected are important.
- Keeping patients and health care workers in a safe environment is critical because if you lose your health care staff, you cannot deliver adequate care, and you lose the confidence of the population.
- People will not come for treatment because they are frightened and because they are not confident that they will receive care that will make a difference.
- Ideally, there needs to be preparation around the core principles of keeping staff safe and training for the delivery of care to critically ill patients. In an outbreak, this background training needs rapid augmentation and deep support – materials and personnel from the global community, more quickly than we were able to muster.
- Despite its image, there is nothing magical about the syndrome of Ebola: it causes a severe, febrile, gastrointestinal illness with lots of diarrhea and vomiting – lots of dehydration. We need to prevent this dehydration, prevent and treat the organ failure and severe metabolic and electrolyte abnormalities that develop.
- We need to deliver care safely, but cannot be reluctant with this therapy – oral rehydration that shifts quickly to intravenous hydration for those who are vomiting – because if we wait until complications of Ebola develop, many more patients die.
- If we respond aggressively with individual patient care – if we have enough people to deliver care for as many hours in the day that patients need – we can save the vast majority from dying with simple and available supportive treatments, even in the absence of an Ebola-specific medication.
Q: Were you ever afraid of getting exposed?
Rob: I cut myself once on a glass vial, drawing up a medication in a treatment facility. Although the vial and my gloves were clean and the true risk was negligible to none, I remember thinking it is completely insane that we have a system that I was handling glass vials in an Ebola treatment facility. This is one of the small but important aspects of infection prevention and control that we have been pushing to change – to do simple things outside the “at risk” zone, before you enter, to reduce any risk.
The time I was most concerned was after returning from Guinea to Switzerland. About a week or so after returning I had the feeling that something was not quite right in my body – the kind of prodromal feeling you have when you are coming down with something.
It progressed over about 48 hours to the point that I was weak and had muscle ache and pains, I didn’t really want to eat. I was checking my temperature after every few hours. I didn’t develop a fever but, because Ebola starts out non-specifically, in the 3 weeks after a deployment, I was very attuned to not feeling well. My family was away for a couple days and I was alone. After a few days whatever it was passed. That was the only time I started to get a concerned personally.
So given where we are now in the outbreak, do you think we are in a better place
Rob: We are certainly not in a better place when you look at the cumulative number of people who have gotten sick, and who have died, including health workers; but, we are in a much better place from the perspective of our collective response. The countries of West Africa have ramped up their response so much and shown great leadership over the past many months.
"If we respond aggressively with individual patient care – if we have enough people to deliver care for as many hours in the day that patients need – we can save the vast majority from dying with simple and available supportive treatments, even in the absence of an Ebola-specific medication."
Rob Fowler, a critical care physician, Canada
While the usual responders were over-stretched very quickly at the beginning of the outbreak, the international community and humanitarian agencies are now robustly responding and sending help in all of the categories of outbreak needs – WHO, MSF, the Red Cross/Red Crescent, International Medical Corps, Save the Children, Partners in Health, Emergency, International Humanitarian Partnership, and others. There are so many more boots on the ground to help Ministries and national staff – the African Union, all the United Nations agencies, the Cuban medical brigade, medical military staff from the China, Canada, the United States, the United Kingdom and more.
Q: When you look back on the year, how would you describe it?
Rob: From my personal perspective, my year with WHO has been sharply divided into a period before and after 21 March 2014.
Q: How did your family handle this period?
Rob: My wife Eva is a physician too and she has the ability to think logically about the modes of transmission. She understands that we can protect ourselves against anticipated risks. My son – he doesn’t fuss too much about the risk part. He just gets annoyed with me and wants to know when I will be home again.
Q: Looking forward, what do you think is now needed to address the outbreak?
Rob: West Africa needs this outbreak to be finished. If you go around the countries now you can see that the usual health care system is paralyzed. Hospitals and healthcare workers have been hit hard by this outbreak, especially so in the first months. There is tremendous excess mortality and morbidity of other diseases and conditions because of Ebola– pregnancies without prenatal care and births without the backup of healthcare facilities, children who are ill but have no hospital to go to. The impact of this non-Ebola morbidity, I suspect, is much greater than that directly from the virus. We need to assist in getting the healthcare system back on track.
For Ebola, the virus, it is difficult to know what the epidemiology will be in 6 months, 1 or 2 years down the road – an outbreak of this size is, of course, unprecedented. It is possible, maybe likely, that we are unable to clear the virus from West Africa completely. Even if human-to-human transmission stops, an animal reservoir may remain, as it does in Central Africa.
This makes it critical that we help to rebuild the healthcare system in West Africa, and we do so with the capacity to perform surveillance for novel and re-emerging infections, and rapid diagnostics across the region, allowing early identification of future cases. With this, and ongoing attention to infection prevention and control, we’ll have the best chance at shutting down transmission before it has the opportunity to lead to another outbreak.
A key lesson of this outbreak is that the world cannot be complacent about communicable diseases and health disparities focused in one part of the globe. First, it is globally immoral. Second, we are too interconnected. There is no “your problem” in 2015 – global health is our collective responsibility. As Ebola has taught us, to ignore it is at our collective peril.
Q: What’s next for you?
Rob: I really love my profession as a critical care physician, helping to look after very sick patients. I want to continue that. I also see however that this role, historically associated with working in an intensive care unit in a very developed healthcare system is too narrow an approach.
Just because people fall through the cracks of a public and acute health care system does not mean that there should be no hope for them. Ebola provides that example. People can become very ill, but with early aggressive care from available, feasible treatments, we can get them through the illness and they can go on to live healthy lives.