Dignitas International’s Medical Advisor, Dr. Adrienne Chan, has returned to Canada after supporting the World Health Organization’s Ebola response in Sierra Leone from December 2014-February 2015. Together with an international group of clinical colleagues and partners, Dr. Chan coordinated the WHO Clinical Management Training Team at the IOM Ebola Training Academy in Freetown, supported Mobile Training, and worked as a Clinical Mentor in Kono District. We recently sat down with Dr. Chan to talk about her experience.
Q. What prompted your decision to personally support the Ebola response in West Africa?
A. I responded to an invitation to support the clinical response from my colleague Dr. Rob Fowler at Sunnybrook Health Science Centre. Dr. Fowler has been working with the World Health Organization (WHO) Ebola response since the first confirmed case in Guinea. I had been thinking about going to West Africa for some time, but was concerned about potentially neglecting my longstanding commitment to Dignitas’ work in Malawi.
Getting involved in this humanitarian emergency was particularly compelling, for me personally, for two reasons. First, I knew that the three countries in West Africa affected by the Ebola outbreak (Guinea, Liberia, and Sierra Leone) were facing real challenges with respect to health system weaknesses and human resources for health. Those challenges resonated with me because of our longstanding work with the Ministry of Health in Malawi.
Secondly, as an Infectious Disease specialist with clinical experience in resource-limited settings and having worked as a clinician taking care of patients and colleagues during the SARS outbreak in Toronto, an outbreak that also had global implications, I thought I might have some helpful skill sets and a unique lens to bring to the response. When the opportunity to work with Dr. Fowler and the WHO Clinical Team in Sierra Leone arose, I knew immediately it was the right thing to do.
Q. What was your role and experience as a WHO clinical consultant in Sierra Leone?
A. I had several roles in Sierra Leone, including provision of clinical mentorship, training frontline health care workers, and coordinating our team. Much of the work we were involved in was very reminiscent of my previous field role in Malawi with Dignitas bridging clinical work, program management, and capacity building. I was involved in everything from providing direct patient care, to scrubbing down tents and throwing out waste for decontamination, to working at a national level on providing clinical input into high-level decision making and policy guidance documents.
In terms of capacity building, the WHO Clinical Team was primarily focused on doing three-phase training. Phase 1 was didactic training – slides, case-based scenarios, problem-based learning, skill stations – to train frontline health care workers, both foreign medical teams and local health workers, on how to manage patients at Ebola facilities as well how to protect themselves, balancing safety with good patient management. We really tried to support and encourage the aggressive style of clinical case management including early and aggressive intravenous hydration and biochemical monitoring that was championed in the beginning of the outbreak by WHO clinicians working on the ground.
Phase 2 was doing dry training in a mock Ebola Treatment Unit (ETU). This gave people who had previously never had opportunity to work in an ETU, a chance to run through clinical scenarios while wearing the required Personal Protective Equipment (PPE). This is particularly important because of the climate in Sierra Leone. Because it’s so hot, especially for people coming from temperate climates, it’s important for health care workers to get the opportunity to be in full PPE for 45 minutes to 2 hours before they even see a patient to get a sense of the profound physical stressors they have to work through while maintaining safety and providing care. We worked with Ebola survivors who acted as standardized patients to mimic several clinical scenarios. Every health worker would put on their PPE and then go through 3-4 clinical stations similar to that of a real treatment centre, which gave them a chance to think about patient flow, to think about how they would plan their activities, and to feel physically comfortable wearing the PPE while caring for their patients. They were also carefully watched with PPE doffing, which is the most important process to protect from health worker infection.
Phase 3 of our training, which I think was the most important, involved sending WHO clinical mentors to Ebola treatment facilities to support red zone mentorship. Red zone mentorship entailed everything from actually taking care of Ebola patients, to conducting clinical assessments of how health workers were caring for patients, to supporting the frontline teams if extra clinical work was needed. For our team, at the height of the outbreak in December, we were doing a lot frontline clinical care and working with team members to carry out aggressive treatment with IV fluids and electrolyte monitoring for patients.
As the epidemic curve declined in Sierra Leone in January, our work evolved to bridging what was happening in the Ebola treatment centres with non-Ebola health facilities. Along with other colleagues, we provided training at the non-Ebola facilities and worked to strengthen the health system so that there would be a safe place for patients who didn’t necessarily have Ebola but required medical attention to be seen. Part of this included managing patients in the district referral hospital along with other partners and MOH staff.
Q. Why do you think it took awhile for the Ebola Response to be properly mobilized?
A. Over the last quarter of a century, on average, there have been typically less than 40 cases of Ebola globally each year. As such, the expertise to respond to outbreaks has been, up until now, concentrated in areas where there was known to be endemic transmission, for example in the Democratic Republic of Congo (DRC) or Uganda.
We have never seen an Ebola outbreak of this magnitude, affecting more than 20,000 people. A year ago, it was simply unfathomable. I don’t think people had a sense early on, what this would end up meaning for three countries with weakened health systems, that had never dealt with an Ebola outbreak before.
Despite the fact that Doctors without Borders (MSF) had been on the ground and was raising the alarm, it took far too long for the rest of the world to mobilize. Initially it seemed that the outbreak was under control, but then there was a spike in new cases last May. All you need is one case – one case to spread to a village, which then spreads to a health facility, which can amplify and wreak havoc, especially in a resource-limited context. There is a really good New York Times story, which nicely depicts the progression of the Ebola outbreak in West Africa.
The difficult reality is that it took time to ramp up a response to an outbreak where there was limited expertise. There has been a lot already written about the failure of a coordinated global response, but there are many factors involved. Much of the delayed response is related to the limitations of health systems and their reactivity in a local context, and the many structural factors that have contributed to health systems weaknesses. In addition, the humanitarian response complex is simply not set up to mobilize quickly to disease outbreaks of this magnitude. Typically disaster response teams are more experienced with dealing with situations like an earthquake – a sudden event with a very predictable outcome or chain of events. With an unprecedented outbreak like this one, the chains of transmission and complexity of contributing factors can make things unpredictable and lessons were and continue to be learned the hard way in hindsight.
Q. What were some of the successes and challenges that you saw?
A. One of the successes includes the massive rollout and adoption of infection prevention and control procedures in a low resource setting. This was something I have never seen before with such scale and rapidity in my previous work. The intense personal protective equipment (PPE) is usually not available in many low resource settings, so the fact that supply chains and trainings on how to wear and remove the equipment was effectively mobilized once the global response kicked in, is really quite remarkable.
The unsung heroes in all of this are the health care workers of Guinea, Liberia and Sierra Leone. They have been working tirelessly day in and day out and have been fighting the outbreak for the last year. They are under impossibly trying circumstances and many of them have lost their colleagues during the outbreak. It is humbling to see their resilience.
One of the great things that we’ve seen is that with adequate resources, facilities are striving to improve clinical case management and that has lead to better survival rates. There was a letter published in the New England Journal of Medicine about the Hastings Police Training School in Sierra Leona, which operates an Ebola Treatment Centre. At this site, health care workers were able to achieve close to 31% mortality rates by following standardized treatment protocols, which is an impressive result compared to previous outbreaks.
There are a lot of challenges. Coordination is a big one. Bringing in new players without previous technical experience in managing this disease or with limited experience in resource-limited settings can be difficult. The health systems component is also a huge challenge. There is a lot of funding and resources being invested into the Ebola response but how much is being channeled to help strengthen the health care systems so that this kind of collateral damage doesn’t happen again? In my time there, I felt like I saw more people dying of non-Ebola diseases, than Ebola. There is a lot of money coming in, but when you are on the frontlines of the outbreak, you often wonder about where it is actually going.
Q. In your mind, what are the necessary next steps to make sure that we are in a better position to respond to the next outbreak?
A. We definitely need to strengthen the rapid response system. The WHO, for example, is doing a lot of reflection right now about what needs to happen next time to ensure we are more reflexive and adaptive in mobilizing the support needed for mounting an effective response.
But ultimately, we need to deal with the root cause of this crisis, which are weakened health care systems stifled by inadequate health care infrastructure and severe shortages in trained health care workers. If all of the investment goes into the Ebola response and after we eradicate it, there is nothing is left to address the collateral damage that has been done to the existing health systems in these countries, we will see exactly the same thing happen the next time an outbreak occurs. I have been working in global health for long enough to be painfully seeing this mistake repeated again and again.
At Dignitas, our work is focused on building capacity of local health care workers and strengthening health care systems. And while health systems strengthening may not be sexy for donors, it is the only way we will be able to avoid this scale of disaster in the future. It has been difficult to return to Canada and see that what is going on in West Africa has dropped out of mainstream media when there is still an ongoing epidemic. Even with the drop in cases since January, there were still 100 new cases last week. We have a moral obligation to not be complacent.