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Special Topics - Ebola

Dispatches

First-person accounts of life on the ground in West Africa and beyond, from members of the Johns Hopkins Bloomberg School of Public Health community—faculty, students and alumni—who have been working to stem the Ebola epidemic.


Elizabeth Serlemitsos, MBA

Elizabeth Serlemitos Country Representative in Liberia 
Johns Hopkins University Center for Communications Programs
Johns Hopkins Bloomberg School of Public Health

This piece originally appeared in the Baltimore Sun

"Ebola response wrongly derided"

1.14.15 | From the mid-1990s on, I was on the ground in southern Africa where the HIV/AIDS epidemic raged out of control. Exacerbating the catastrophe were the very development partners and donors responsible for combating the disease. Rancorous competition for funds and turf wars often got in the way of progress. Looking back, I wonder if that would have been the case had the international response to HIV/AIDS displayed the leadership, cooperation and dedication apparent in Liberia's response to Ebola today.

As I work with dozens of donors and partners on the Ebola frontlines in Liberia, it's difficult to accept news reports of rampant disorganization, poor planning and infighting. These dispatches may reflect the initial challenges of pooling our resources in the most productive ways, but they have not told the entire story of the work taking place in Liberia in the battle against Ebola. My colleagues and I are working in harmony with one another and with Liberia's Ministry of Health. What's more, we see progress. Ebola infection rates are declining in Liberia, a testament to a level of cooperation that I haven't seen in 20 years of living and working in Africa.

To read the full article, click HERE


Thomas KirschThomas Kirsch, MD, MPH

Director, Center for Refugee and Disaster Response

12.4.14 | Greetings from Monrovia, Liberia. It seems a bit ironic that the passengers disembarking from our flight from Brussels are screened for Ebola before they enter Liberia.

I’m working at the Ebola Emergency Operations Center, as well as at the MOHSW (Ministry of Health and Social Welfare). Both are bustling for 16 to18 hours a day, and staffed by some all night. They are full of interesting, smart and committed people from around the world with the Liberians leading and working harder than anyone. 

The strangest thing about working here, as others have noted, is that you cannot touch anyone. No handshakes, no pats on the back, just little awkward waves in the air. The U.S. military likes to do elbow bumps, but mostly it's nods and waves and 'virtual' high-fives. Life is tough without a hug or two a day.

Monrovia Airport
The Liberia International Airport. Only two airlines fly in and out of
Liberia these days, 
Brussels Airlines and Royal Air Maroc.

The regular health care system in Liberia has been severely affected by Ebola. More that 160 health care workers have died, many hospitals have closed, people are afraid to go to a hospital or clinic because they might get infected. The John F. Kennedy hospital in Monrovia is the largest hospital in Liberia and was the only teaching center. Now it is essentially closed and people have few options for routine and emergency – that is, non-Ebola – care.

Rebuilding the health care systems in West Africa is an important next step to provide care now and prevent further epidemics in the future.

Monrovia Medical Center
The John F. Kennedy Hospital in the Sinkor district of Monrovia.

There is an amazing sense of normalcy here. People are in their bright and best Sunday clothes walking to church. There’s noisy traffic, open shops, voices and laughter around. 

But there are washing stations with bleach solution in front of every building and you get your temperature checked every hour or so it seems.

Life goes on despite it all.

* * *

Things seem to be calming down in the States, with no new Ebola cases in over a month. Here are some Ebola facts to fight the hysteria:

1. There have been about 1,000 foreign health care workers in West Africa in the past 6 months. Fifteen have contracted the disease, one died (maybe two, I haven't been able to confirm). Therefore, if you provide care, working every day in horrible, dangerous conditions in the Ebola tents, you have a 1.5 of 100 chance of getting Ebola and a one of 1,000 chance of dying.

2. According to a U.N. staff member I spoke with, there have been 3,000-4,000 foreign bureaucrats, scientists, admins and other staff working in West Africa on Ebola in the past six months and NONE have contracted Ebola. That is a 0% chance of contracting Ebola.

3. In Liberia there have been about 2,650 confirmed cases of Ebola, let's say that is a big underestimate, so 5,000 cases. (WHO believes the official numbers under-represent the true cases by as much as one-half) There are 4.9 million people. So that means about 1 in 1,000 Liberians have contracted the disease. Most of these people were living in squalid slums.

4. Thomas Duncan, the unfortunate man from Liberia who went to Dallas and died from Ebola, stayed at home after he was sent home from the ER. He was very ill. Before he returned to the hospital, he was cared for by four people there for two days and none of them contracted Ebola.

5. At the hospital, where he was treated and eventually died, the two infected nurses did not pass on the virus to anyone, despite freely mingling with the public (and other patients) for two weeks.

6. None of the health care workers who treated Craig Spencer in New York City -- the U.S. doctor contracted Ebola while working in Guinea -- and Martin Salia in Nebraska contracted Ebola. Dr. Spencer survived. Dr. Salia, who reportedly was in grave condition when arrived in the U.S. for treatment from his native Sierra Leone, did not.

Please think about the facts before you freak.


Megan VitekMegan Vitek, RN, MPH

Johns Hopkins Bloomberg School of Public Health, MPH ‘13

11.25.14 | In late August, news of the devastation in West Africa caused by the current Ebola epidemic started to make its way to the states. It became a conversation point between my friends and me in the D.C.-based development world. Talk circled around economic impacts, possible food shortages, potential for political unrest, supply chain issues, and most markedly, the need for clinics and clinicians. In a way that a car wreck makes you slow down on the highway, I was fascinated by this epidemic and started to search out information about Ebola and the response. 

Unfortunately, the outbreaks were not a one-time accident that could be cleaned up by an ambulance or two. There seemed to be a domino-like effect of one city or area having an outbreak and a neighboring county quickly following suit. Classic epidemiologic surveillance was failing to find the sources of the infection quickly enough and stop the spread. In the weeks leading up to the final declaration of a state of disaster, a good friend, Sara Phillips (we met at the Bloomberg School during the MPH program), and I started talking about the possibility of responding to this epidemic.

We both felt a fascination with this virus from a clinical and public health point of view. But, more importantly, we both began to feel a compulsion towards caring for the sick affected by this epidemic. We both felt called to use our clinical skills – I have an emergency nursing background and Sara is a nurse practitioner – to respond to this disaster.

Through a series of contacts and emails, we started having conversations with recruiters with International Medical Corps (IMC). The timing felt providential. I was coming to the end of year working as a public health consultant and had been looking for a new opportunity. And, the icing to it all, for the first time in years my resume exactly fit the job description. 

In several ways, I felt uniquely prepared and called to this response. During my time at Hopkins and for the last year afterwards, there was a bit of frustration in not knowing how to combine my clinical skills with the public health world. It seemed that this was the opportunity to utilize both. And with that, I accepted a position as an Emergency Response Nurse in the Ebola Treatment Unit (ETU) in Suakoko, Liberia. Sara also accepted a position there.

Having a buddy during the decision process was invaluable. There was and is a lot of fear surrounding this virus. Some warranted, some not. But to know that I was not walking into this disaster response alone, both propelled me forward and buoyed me. Friends and family, as well, have been an amazing encouragement, such that, I felt as prepared as I possibly could be to respond to this disaster.

As of writing this, Sara and I have been in Liberia for a week or so. Despite reports of the virus slowing, our ETU has been full day and night. We have seen an average of 10 triage patients a day, each of them waiting for results on whether they are Ebola positive or negative. The confirmed ward has an average of 30 patients – some on beds, some on mattresses on the floor, and others sitting outside when they can tolerate it. There is a lot of sadness here and seemingly unexplained death (except to say as related to Ebola). But there is joy for those who beat this virus, who walk out of here, and who often come back to work in the confirmed ward.

Some of our most valuable workers are our recovered, formerly Ebola-positive patients. Their status means that they can walk around the ward that houses people with suspected and confirmed Ebola cases like a normal health care worker. No gowns or masks or other personal protective equipment needed. As a result, unlike the rest of us who need to come out after two to three hours, to remove our protective gear for a break, and might not have the stamina to go back for another round, they can stay in for an entire shift. Some act as ancillary nursing staff, others have become child caregivers (the children in our ward rarely have caregivers who are alive or who are well enough to care for them). Regardless of their role, it is both an immense help to the unit and an incredible encouragement to both patients and staff to see them walking around, alive.

The next few weeks and months are an unknown. Transmission seems to be moving further out into remote areas where surveillance and personnel cannot penetrate. There have been talks of shifting to more a mobile response to effectively decrease transmission at the start and source of the virus. Regardless, I am thankful to be here now, to be working amidst this epidemic, and to be a part of public health history.


anna-hellland-cropped.jpgAnna Helland

Senior Program Officer
Johns Hopkins Center for Communication Programs

Johns Hopkins Bloomberg School of Public Health

11.17.14 | As soon as I arrived in Monrovia – actually before I even arrived, as I flew in from Brussels on a near empty plane – I was forced to face the emotional effects of the Ebola outbreak, greeted by airport officials wearing gloves and masks, washing my hands in bleach water for the first of many times, and agreeing to have my temperature taken, also for the first but not last time.

As we drove to town from the airport, traveling in a vehicle that smelled of the bleach water sprayed for my benefit and passing two of Monrovia’s at-capacity Ebola Treatment Units, I asked my driver if this felt like a war. Was it bringing memories of the war back to people? The war is still so close to the surface in Liberia, with many of my conversations with Liberians eventually moving towards the sharing of tales, both funny and tragic, of the many years of civil strife.

I certainly felt as if I had entered a state of emergency and was afraid this would bring stressful memories of the war bubbling up to the surface. It felt to me like war. How my driver responded surprised me: he said it was worse than war. “At least during the war, you knew who had a gun. With Ebola, it could be your brother who infects you without knowing.”

It’s this not knowing – in the community, at the health facility, even within a family- that is bringing about changes in behaviors and social norms that highlight an underlying emotional context, one of unease and distrust.

A new normal seems to be developing and at its base is this feeling of distrust. In previous trips, I hadn’t quite mastered the Liberian handshake, which requires multiple changes in hand positions and ends with a snap (The snap is what’s still giving me trouble). As through much of the continent, a handshake begins all new social interactions, leading to queries on the family and the previous night’s sleep and thanks to God for bringing us to a new day. But touching is no longer allowed, and the strain this causes in social situations is clear as those talking keep their hands in their pockets or their arms crossed to prevent the temptation to put out a hand or even casually touch an arm for emphasis during a conversation.

The ever-constant bleach water containers for washing hands and the security guard to take your temperature are also part of the new normal. Taxis are no longer crammed with passengers. Now they are allowed to take only three in the back seat, and even then, people seemed to be trying hard not to touch their fellow passengers, for fear of becoming contaminated.

All of this fosters an environment of distrust, and the feeling permeates through various layers of society.

Health care workers haven’t been too keen on caring for community members, fearing Ebola will come from those entering their clinics.

Community members themselves fear service providers as they’ve heard so many of them have already died of Ebola and wonder if maybe there is something to the rumors circulating that Ebola is actually injected at the treatment centers.

Distrust has bubbled up to the government level as seen in the unfortunate events in West Point in August, where the government attempted to quarantine an area with high numbers of Ebola cases and overcrowded conditions. Many from West Point are angry with the government for this botched response and the subsequent violence. Residents from West Point have been stigmatized outside their community as coming from an Ebola area, much like those coming from Lofa County were stigmatized at the beginning of the epidemic.

And finally, the health system, which had only just begun to improve during this first decade of peace, has failed them all – health care workers and community members alike. When Ebola made its way to Lofa County from Guéckédou in Guinea in the spring, the Liberian health systems – and it can be argued the global community- were caught off guard, without the needed weapons to fight this type of war.

If this is worse than war, as my driver asserts, intense efforts are needed to foster hope and a renewal of trust- between health care workers and their clients, between the government and its people, and even between brothers as families work to keep themselves and their communities Ebola-free. Trust is not only the key to getting ahead of the epidemic, it’s also the key to rebuilding the health systems in Liberia, which are weak but had been getting stronger. Regaining trust means community members and health care workers feeling confident in their relationships with each other and the services provided. It means trusting themselves and each other to identify the solutions that work best for their communities. 

While trust is the solution, social and behavior change communication efforts are the key to fostering this change. These health promotion efforts provide accurate information through strategically crafted messages designed to rebuild trust in the health care system and its workers.

A glimmer of good news from Liberia the last few weeks, with a drop in Ebola cases and more beds available, may help establish trust again. The successes seen in Lofa County, which earlier this year had the highest number of cases in the country, seem to rest squarely with local leadership and community ownership and engagement. Health promotion efforts like ours have encouraged communities to engage by allowing community members to identify their own solutions. This begins to build that trust between them and the healthcare system that promises to provide the best care possible while being sensitive to local customs if care comes too late and a burial is required instead.

Trust allows for these small successes to grow into larger and larger successes and to rebuild what is now a devastated health system. Social and behavior change communication efforts foster the trust to not only getting the outbreak under control but also in leaving systems in place to be better prepared for the next emergency, if and when it comes. 


David PetersDavid Peters, MD

Professor and Chair, Department of International Health
Johns Hopkins Bloomberg School of Public Health

11.11.14 | Scars from Liberia’s long-running civil war have been exposed with the current Ebola crisis. Like many post-conflict nations, there isn’t a lot of trust in the government. Services like simple health care have suffered. Health care workers have gone on strike four times in the past year because they are not paid and don’t have the equipment to do their jobs safely. And that was before this Ebola outbreak began.

This year’s Ebola epidemic laid everything bare. Liberians became ill and health care workers weren’t able to provide care or find new cases and isolate those who were infectious. Health care workers themselves got sick because they didn’t have or use protective equipment – more than 100 health care workers have died in the outbreak. Many of the sick were afraid to go to clinics. Health care workers were afraid to treat them. Communication was poor; the response delayed. All of this created a perfect storm and led to the outbreak we are seeing today.

Our team traveled to Monrovia, the Liberian capital, on Oct. 17 to help with Ebola control and lay the groundwork for recovery. We are working with Liberia’s Ministry of Health and Assistant Minister Tolbert Nyenswah, a recent MPH graduate of our school, to determine how to rebuild the health system in a much more strategic way and to restore trust. The needs are so great: human resources, pharmaceuticals, information systems, community engagement. We know from other outbreaks that the key to containment is a quick response, something that didn’t happen this time.

The panic in the streets from the early days of the epidemic is gone. Cooler heads are prevailing and the time is right to start planning the next phase, even as the disease still manages to kill most of the people who contract it. There are now enough beds for the ill but there is still a shortage of health care workers. There are hand-washing stations in public buildings and no one touches one another. There are still many problems to overcome. The ambulance system is inadequate, protective equipment is still scarce in some of the rural areas. We are trying to address these problems by supporting health workers from the Democratic Republic of Congo, which has survived seven Ebola outbreaks, to come to Liberia to care for the sick there. We are working with Liberia to improve their community assessment and engagement, to provide a community-based medical and public health approach to intervention. We are working together to build a new foundation.


Elizabeth Serlemitsos, MBA

Elizabeth Serlemitos Country Representative in Liberia 
Johns Hopkins University Center for Communications Programs 
Johns Hopkins Bloomberg School of Public Health

11.6.14 | Everywhere I go in Monrovia, the capital of Liberia, they take my temperature. Eating at a restaurant? There’s someone wielding a thermometer at the door. Headed into a building for a meeting? Same thing. Even when I pull up to park at the apartment building where I am staying, I have to roll down my window so an attendant can hold a thermometer up to my face to make sure I don’t have a fever. A fever is the first sign of Ebola and I am living in the epicenter of the outbreak.

This is just the new normal here. We don’t shake hands when we greet each other. We wash those hands all the time, mostly at washing stations set up by the entrances of every building. There was some hysteria here in the early days of the outbreak, I am told, but shops and restaurants on the streets I walk here in Monrovia are open now and it is business as usual. We are vigilant, but we are calm. It is hard to get Ebola. We know that it’s not casual contact that spreads this horrible disease. It is nurses and doctors who care for the sick who are at risk, relatives who physically comfort those with the disease, those who try to prepare the dead for a proper burial.

I arrived in Liberia on October 10 and plan to be here for as long as it takes to turn things around. By next month we will be a team of six on the ground (three Americans and three Liberians) here with the Johns Hopkins University Center for Communications Programs, funded by USAID to support the Liberian government’s response to the Ebola outbreak. Our work here is to communicate with Liberians about Ebola, quieting rumors and fear and giving them the information they need to help protect themselves and their families from Ebola.

The first message, back in the early days of the epidemic, was that Ebola is real. There were many questions and doubts. Conspiracies were everywhere. That message is now getting through. Now we have moved on to new messages: Practice good hygiene, like regular handwashing. If someone in your house is sick, get help and don’t try to treat him yourself. Keep the sick person isolated. If someone in your house has died, get help and don’t touch her body. We have been helping to strengthen the call center that was set up to provide that help. We think the messages are getting through.

Soon we hope to move to phase three: welcoming survivors back into the community, as the heroes that they are.

When I open my laptop and read headlines from the United States, I find it hard to believe the level of hysteria so many miles away. The risk is so miniscule. Only those who have directly treated patients in the United States have gotten sick and yet people are afraid to travel to Dallas? It makes no sense.

Shortly after I got here, I attended a big WHO briefing and heard a report from Lofa, a county in northern Liberia. The data indicates that things are starting to turn around up there. Strong, motivated leadership coupled with an engaged community look to be making the difference. It’s not the story everywhere. This epidemic is different in different areas. But in an outbreak like this, the bright spots are something to celebrate. Just without the hugs or the high-fives.


William Brieger, DrPH

Bill BriegerSenior Malaria Specialist, JHPIEGO
Professor, Department of International Health
Johns Hopkins Bloomberg School of Public Health

11.3.14 | I got back from Liberia last Tuesday evening. I’d gone with several JHSPH faculty, including David Peters, chair of the Department of International Health, to work with the Liberian government on three areas of Ebola containment: data collection, case management and community mobilization. In my 10 days there, I did not see any Ebola patients, or do any work in a clinical setting or, as far as I could tell, come in contact with anyone sick with Ebola. Everything was committee meetings and planning meetings.

I was planning to fly to New Orleans on yesterday to attend the annual American Society of Tropical Medicine and Hygiene (ASTMH) conference. I was planning to fly back to New Orleans later this month, to attend the American Public Health Association (APHA) annual conference. That all changed last Wednesday when, after being back in the States for less than 24 hours, I got an email from conference organizers notifying me that the state of Louisiana was prohibiting anyone who had traveled to the three affected Ebola countries – Liberia, Guinea and Sierra Leone – to travel to Louisiana until they had been back in the country for 21 days and had waited out the incubation period. The Louisiana Department of Health and Hospitals also sent an email with a letter attached that explained their policy.

Shortly after that, I got a phone call from the state health department. They were almost apologetic that they had to inform me of measures that were contradictory to CDC recommendations. But they were also quite frank about the state’s policy, telling me that authorities would take action and quarantine people if anyone who’d traveled to the affected West African countries came to Louisiana before the 21 days were up. One said that on arrival I might expect to be placed in my hotel room for the duration of my stay. They regretted any financial loss to me.

I must say I wasn’t expecting this. I guess I was naively assuming that two national – and really international – health conferences would be seen as a prize to any state or city, and that any state would be welcoming rather than afraid.

One good thing in all of this is that the CDC is definitely doing its job monitoring people. When I arrived back in the States, the CDC asked to provide detailed information about my plans for the next several weeks. I indicated I was heading to New Orleans on November 2nd. The CDC relayed that information to the Louisiana Department of Health. It all happened in a space of a couple of hours. I did a lot of scrambling to cancel airlines reservations, of course the airlines are charging fees and will only give me credit toward future flights, so no refund. The hotel let me cancel my reservation, and the conference is offering a full refund.

What am I missing by missing the ASTMH conference this week? I’ve been going to this conference for years as it is the biggest annual malaria gathering – though of course other tropical concerns are covered. This year I was going to present a poster, on malaria, plus participate with? a Jhpiego team in a symposium. Fortunately, the co-author of the poster is able to attend the conference. In additional, the Royal Society of Tropical Medicine is going to have an editorial board meeting. (I’m on the editorial board of their journal, International Health.) So, I’m missing that as well. And apparently, there is no way to watch the conference via webcast.

In addition, I had been planning to tweet out the conference, as I’d done in the past, and blog about it, too. So I won’t be able to do that.

I can’t help but note that Louisiana is at the bottom of state rankings as far as health indicators go. Keeping a few people out of the state over Ebola concerns – the governor’s making a big hoo haw over this – is not going to help the people of Louisiana. This policy of course goes against the CDC’s.

As I mentioned, I was supposed to go back for the APHA also in New Orleans. Only my 21 days don’t expire until part way through the APHA. So I’m not going to that conference either. All of this drama for trying to help people an ocean away deal with a public health crisis.


Anjalee Kohli, PhD, MPH

Anjalee KohliJohns Hopkins University School of Nursing
Johns Hopkins Bloomberg School of Public Health, PhD class of 2013

10.28.14 | In the Democratic Republic of Congo, health care experts demonstrate calm and competence in their response to Ebola. They have been through this before. Seven times they have tackled Ebola outbreaks in rural villages. Through coordinated clinic and community-based efforts, they have addressed health care needs, educated people on prevention and treatment, reduced fear and stigma and conducted continuous surveillance for new cases to stop the outbreaks.

I recently returned from Kinshasa, the capital, where I was fortunate to be involved in a Johns Hopkins University project to develop protocols and a training program to prevent and respond to Ebola in the DRC and West Africa. The Congolese government has offered to send 1,000 trained professionals including epidemiologists, health care workers and communication specialists to work on multidisciplinary teams to assist the response in Liberia, Sierra Leone and Guinea. Our job is to help them do that.

We met with Congolese experts who have responded to Ebola. I was impressed with their approach to this disease: collaborative, calm, confident and adaptable. There is no panic. This approach is in stark contrast to the US where the media has generated fear and panic with their Ebola coverage.

We learned from their many experiences. Congolese experts described how families initially refused to send patients to the clinic for evaluation and treatment for Ebola due to fear of foreigners and local perception that the clinic stole blood from patients and caused their death. But the Congolese team persevered, reaching out to local leaders and engaging recovered patients in education and referrals. They spoke of how fear and negligence were drivers of Ebola, exacerbating risk for exposure and delaying treatment. As the Congolese further develop and formalize their Ebola prevention and response program, research, communication and collaboration are important components to improve the global Ebola prevention and response. We can learn a lot from them.