Although Drs. Ian Warrington and Eric Crawford both work at Washington-area hospitals, the two met for the first time in Boston this March, at the start of a journey that would see them practicing medicine thousands of miles from the comforts of an EMA-run emergency department.
Driven by a common interest in international disaster response, both physicians took leaves of absence from EMA this spring and signed up for a six-week deployment to West Africa with Partners In Health (PIH), a Boston-based nonprofit organization that has played a key role in the response to the Ebola epidemic. By the time they arrived, the days of Ebola treatment units overflowing with infected patients had finally passed, but extreme challenges remained for the exhausted healthcare systems the virus left in its wake. Neither Warrington nor Crawford cared for Ebola patients during their terms, but both were involved in PIH’s efforts to facilitate the long-term recovery of hospitals and clinics that lack the human and material resources to meet their regions’ daily healthcare needs and stop another inevitable outbreak. Here the physicians tell how the work to heal West Africa is far from over.
Dr. Ian Warrington – Koidu, Sierra Leone
The fearful media buzz surrounding the first cases of Ebola in the United States in the fall of 2014 frustrated Warrington, an emergency physician at Sibley Memorial Hospital for the past two years. There were panicked public calls for airport closures and questionable political demands for strict isolation of returning medical aid workers. But science said that a more effective way to curb the outbreak would be to boost the number of clinicians in West Africa.
“One day I realized, if I feel really strongly that we need to get people over there, I’m sort of the ideal candidate,” says Warrington, who is just three years out of residency and did a short deployment to Haiti with PIH following the 2010 earthquake. “If I’m not going over, who is?”
Warrington approached his department chair at Sibley and asked if there was a way he could make the trip.
“I felt very supported,” he says. “I had a lot of colleagues who I worked with over there who really had bad times with administrations that resisted for many reasons. My experience with EMA was really positive.”
After a week of orientation in Boston, Warrington and a group of PIH colleagues who included Crawford arrived in Freetown, Sierra Leone’s capital, on March 8 for training sponsored by the Ministry of Health in partnership with the World Health Organization and the International Organization for Migration. From there, Warrington and four colleagues were sent to Koidu, the diamond-mining capital city of the eastern district of Kono. For four weeks, the team of two doctors and three nurses worked in Koidu Government Hospital, the only such facility in the area. Their mission was two-fold: practice continued caution against Ebola and assist in the rehabilitation of the hospital.
Kono District had not seen an Ebola case in weeks and more than a year into the outbreak, the hospital staff was weary of the tedious process of monitoring for symptoms in each arriving patient. But vigilance was critical. A single failure to quickly identify and isolate a possible Ebola patient and safely transfer him or her to one of the designated Ebola treatment units located throughout the country could erase months of life-saving work.
“That is the fundamental thing that completely destroyed the healthcare system,” Warrington says. “Those hospitals are so cramped and crowded and have such poor hygiene that the moment you have one Ebola patient, it’s just game over.”
Warrington’s team focused on infection prevention and control, encouraging the workers posted at the gates of the hospital to check temperatures and go through symptom questionnaires with each arrival. Inside the hospital’s sweltering and congested wards, they helped the local staff members monitor for Ebola-like symptoms each day of a patient’s stay.
The team also assisted in PIH’s early health system strengthening efforts in Koidu. Clinicians worked shifts seeing patients in the hospital to supplement the lack of qualified healthcare workers and provided training and education whenever possible. They also worked on projects to enhance the quality of care, such as implementation of a system for recording vital signs and medication administration on patient charts. Shortly before Warrington’s group arrived, the hospital had instituted a case management system to help indigent patients access care. Despite the gains, progress was often frustratingly slow.
“Being in emergency medicine kind of helped in the sense that I’m a little bit more comfortable working with less information and doing what I can at this moment and accepting that I’m not going to be perfect,” Warrington says.
But it didn’t take away the pain of losing patients because there were not enough staff, supplies or equipment to provide timely care. Corruption was also a discouraging reality, and one of the many root health system challenges that Warrington says will have to be addressed in order to successfully guard against future outbreaks of diseases like Ebola.
By the time Warrington headed back to the United States in mid-April, the number of new cases of Ebola in Sierra Leone had dropped to about 10 a week; a similar rate continues today. Back in Washington, Warrington completed three weeks of voluntarily quarantine at home before returning to work at Sibley, where he takes any opportunity to reiterate the truth about Ebola and the ongoing development needs in West Africa.
“When you take a fire when it’s a tiny little spark and you step on it, it’s done. But if you drop a spark into a pool of gasoline, it’s a disaster,” he says. “You can’t separate the effects of poverty from infectious disease. This is an ongoing disaster that really without significant help will not go away.”
Dr. Eric Crawford – Harper, Liberia
After the week of training in Freetown, Crawford parted ways with Warrington, traveling to the coastal Liberian town of Harper, near the border with Cote d’Ivoire. The Carroll Hospital Center pediatrician was assigned to J. J. Dossen Memorial Hospital, where three local doctors served a population of 350,000 people spread throughout southeastern Liberia.
Despite picturesque scenery, this remote town, an 18-hour drive from the capital in the dry season, struggled with extremely limited healthcare resources. But the environment was not entirely new to Crawford, who has extensive humanitarian experience, primarily in Haiti and other parts of the Caribbean. When considering an organization to assist in West Africa, he chose PIH specifically for its unique approach to international relief work.
“I think there are a lot of NGOs that address acute problems, but not the chronic ones that lead to it. PIH tries to address long-term healthcare infrastructure issues,” he says.
The issues in Harper were daunting. J. J. Dossen had no running water and only occasional electricity. Due to a lack of funds and a weak supply chain, some days there were no medicines or basic medical supplies available. The area had long suffered from a shortage of qualified healthcare workers, and the government’s inability to pay wages at the peak of the Ebola crisis had led some of the few they had to stop reporting for duty.
“The fact that any of those people were still going to work every day and still doing what they could to help anybody was amazing to me. It was inspiring,” Crawford says.
During Crawford’s tenure, Liberia saw its number of cases dwindle to zero and began the countdown to being declared Ebola free. Still, the need for vigilance remained, particularly since so many of the area’s endemic diseases, like malaria, exhibit symptoms that are consistent with Ebola. The PIH team in Harper helped staff an Ebola treatment unit, isolating and testing symptomatic patients, none of whom turned out to be positive. They also helped establish border checkpoints to monitor for symptoms in travelers, a situation that was complicated by the presence of United Nations-run camps for Cote d’Ivoire refugees.