Rob Fowler, a Canadian intensive-care doctor at Sunnybrook Hostpital in Toronto, says that over the course of the 2014 Ebola outbreak in West Africa, the efforts of himself and others involved helped move clinical care in the right direction.
I went to the World Health Organization (WHO) in Geneva in 2013 on a sabbatical. The goal was to do work in international health care; to donate my time in some naive, altruistic way. In March of 2014, there came word of an Ebola outbreak in West Africa. Every couple of years there's an outbreak of Ebola, but West Africa hadn't seen the virus before, so that was a big deal.
The WHO has a usual outbreak investigation process, which is to first do epidemiologic investigations, figure out what's happening on the ground and help plan a response. Rather suddenly, I found myself in Conakry, the capital of Guinea, to do that. I was partnered with Tom, an infectious-disease doctor from Britain.
Tom and I were tasked with going to local hospitals to see if they had come across any patients that had a syndrome that might be Ebola. One of the first hospitals we went to was a rather nice boutique hospital the Chinese government had set up, mostly for business and industrial clients in the area. Surprisingly, the hospital was empty except for one floor that had seven or eight patients on it who were being cared for by one nurse.
They didn't know it was Ebola, but they knew it was bad. Two or three weeks prior, a patient had come in with abdominal pain and was taken to the operating room. Within seven to 10 days, the surgical staff all started getting sick. The patient died and then the surgical staff started dying one by one.
When we got there, the patients on the ward were almost all health-care staff. A couple of them were very sick, a couple were in the middle phase of an illness and one was actually getting better. The nurse told us that during the night, a doctor had died. He was still in his room, which was a complete mess. Blood was everywhere and there was no one to help move him out of his room.
Tom and I realized that Ebola was already in this large, crowded, poor city – an environment it had never been in before. Very quickly, we changed from being part of a small team doing public-health epidemiology, to being doctors faced with patients who were very sick and being cared for by one nurse. Tom said, "Let's go. We are going to put in IVs and we're going to treat these patients."
We had a box of personal protective equipment (PPE) that you would never find in our hospitals – almost like a negligee meant to keep stuff off your body. We did have gloves, masks and face shields – and that was pretty much it. So we started treating patients, with heavy attention to not putting ourselves at risk.
We met with the hospital administrator, who was understandably beside himself. His first question was, "Can you take these patients someplace?" So we said to the administrator that we could take his patients if he gave us all the hospital's medical supplies. We brought two big cardboard boxes to the pharmacy and they dumped the whole pharmacy into them.
One by one, we started to take the patients over. There were a few terrific Médecins Sans Frontières (MSF) nurses in town and we started the Ebola-treatment facility with them. Our goal was to provide good care, safely, to patients that usually get minimal to no care.
The first patient died not long after arriving. He was destined to die and should probably never have been transferred. He was a heavy guy – there were not enough people to carry him out of the room. Eventually we were able to bring him to a Red Cross truck – they do a terrific job in these outbreaks of handling bodies safely – and they started the process of safe burials.
It was a huge challenge to provide care that we thought was reasonable quality, because we started with a very small staff. The PPE the nurses and doctors were using was a yellow plastic suit that completely covered them; not a pixel of skin was exposed. They also had to wear two masks and goggles. In the middle of the day, it was in the high 30s C, and if they spent more than 45 minutes inside the PPE, they would get lightheaded and faint.
MSF, which is terrific operationally, came in with tents for a pharmacy, better water sanitation, piped chlorine for disinfection and a place where you could get in and out of PPE. It started to look like something you could imagine in ordinary health care. Over the next month or so, we were usually treating between 20 and 30 patients at a time, with four docs and eight nurses.
Community work to prevent infection is the most important and in the big picture makes the work inside a treatment unit seem trivial. That said, the mortality was around 80 per cent at the beginning of the outbreak and decreased to lower than 40 per cent by the end. The mortality of folks that were evacuated to Europe or the United States was less than 20 per cent.
Although this isn't definitive, we feel that over the course of the outbreak, we at least helped move clinical care in the right direction. You can't feel good about an outbreak where nearly 30,000 people got infected and 40 per cent of them died, but from a narrow perspective, I think we helped.
Rob Fowler is a Canadian intensive-care doctor at Sunnybrook Hospital in Toronto who went to West Africa during the 2014 Ebola outbreak.
This interview by Andreas Laupacis has been edited and condensed. The story first appeared in Healthy Debate, an online publication guided by health-care professionals and patients that covers health policy and evidence-based medicine in Canada.