Interview with OHHW Keynote Speaker
Dr. Stefan Schmiedel on the lessons learned about Ebola in Sierra Leone
(September 19 st, 2019) At OHHW 2019, Stefan Schmiedel, a specialist in tropical medicine, will speak about the lessons learned during the 2014 Ebola outbreak in West Africa and about sending health professionals into areas where the disease is endemic. Insights into the situation of the aid workers on the ground are given here in this advance interview.Mr. Schmiedel, at the height of the Ebola outbreak, you worked for Médecins Sans Frontières (MSF) for several weeks in Sierra Leone. What prompted your courageous decision to go into one of the epidemic’s epicentres?
Here at UKE (the University Hospital in Eppendorf), we treated a patient in 2014 who had contracted Ebola, a 36-year-old World Health Organization (WHO) worker from Senegal, sent to us by WHO. We treated this patient and kept him under our care for several weeks in the treatment centre for highly infectious diseases, an extremely secure, isolated reception centre. He then fortunately recovered.
The crisis occurred in West Africa in 2014, with many thousands of people contracting the disease. We now know that there were 25,000 cases of Ebola in Sierra Leone, Liberia and the Conakry region of Guinea. In Sierra Leone especially, the spread of the disease among the population spiralled out of control. The health professionals on the ground were overwhelmed and healthcare provision collapsed. Appeals were made internationally, amongst others by MSF, for trained medical personnel, to provide assistance. I was interested in taking part from the medical point of view, as well as, obviously, for humanitarian reasons.
How did you find the situation on the ground, and what were you able to do in practical terms?
I was the medical director in charge of one of the treatment centres, of which there were four at the time, and I tried, as far as circumstances permitted, to provide medical care, continuing in fact what others had already begun. One of the epicentres of the epidemic lay in Kailahun, a remotely situated town in Sierra Leone. In September 2014, at the time when I was in West Africa, the outbreak was just reaching its peak. Our hospital had only 100 beds and all of them were occupied by Ebola sufferers. Every day, around 10 new patients were brought in and the same number died. We lost about 50 percent of our patients. In the region at the time, Ebola was the only thing that was still being medically treated. Aid organizations and WHO naturally also recruited local staff, and they were very successful in this. In addition, the Ebola treatment centres received staffing support from Europe, the USA and Japan.
What did the treatment look like?
A rather conservative programme of medication consisting of antibiotics, fluid therapy and nutritional therapy, anti-malaria medicine, analgesics and antipyretics. We cannot be entirely sure whether the treatment led to a decisive improvement in survival rates. There are no verified data on this, but of course we hope that it did. I believe that it was crucial, having given the people something to eat and drink, to keep feeding and giving them plenty of water. Ebola patients are too weak to do this for themselves. Death from Ebola is agonizing and it is also traumatising for those affected to witness the suffering and death around them. At the same time, the rest of the health care provision in Sierra Leone was, under the circumstances, certainly not as one would have wished.
What measures were available to the medical staff to protect themselves from infection?
We wore protective suits that cover the whole body. As you can imagine, that isn’t exactly pleasant in the heat. It’s strenuous to work in those conditions, and it makes communicating with patients virtually impossible. In these situations, keeping safe is always down to teamwork. Even putting on the protective suit is carefully scrutinized, and minutely regulated every step of the way. However, most danger is attached to taking off the suit, because at that point, the wearer has already been in contact with the virus. Someone is always standing by to help and disinfect, with a further member of the security staff checking that everything proceeds as it should. Furthermore, we were kept in isolation in the camp. It is not so much at work, where strict precautions are taken, that danger lurks, but in private life, for instance when visiting someone at their home or shaking their hand. Of course, we were not allowed to do such things. We really were shut away from everything, like being confined to barracks.
What psychological protection is available for healthcare workers taking part in such a demanding humanitarian operation?
There was so much work, so much pressure, that we weren’t conscious of the psychological and physical stresses while we were actually in Kailahun. We stayed in the camp seven days a week, together day and night in a small group, in circumstances that were far from luxurious. That is exhausting. But you don’t feel the full force of the stress until after you get home. While we were out in Sierra Leone, we were always very aware of being privileged and genuinely safe, also because not one of us suffered from the disease.
Aid organizations like MSF can call on decades of medical experience in disaster relief. The organization has, for example, made sure that it only sends mentally stable professionals with several years’ experience into the Ebola area, ones already used to working in the tropics and to humanitarian operations in developing countries. Preparatory training was given concerning safety aspects, but also in the management of psychological stress. Psychologists in the camp came for supervision and kept an eye on us, ensuring that the team functioned well as a unit, and also looking out for any healthcare workers giving cause for concern and who were in need of repatriation.
During the catastrophic Ebola outbreak, periods in the field were limited to four weeks. This was a special precaution, since healthworkers normally stay out for six weeks. Before flying back to Germany, we were again offered psychological aftercare in Amsterdam.
None of this, however, should make us forget how motivating it is to do something as meaningful as this. What has stayed with me is how well the group cooperated, their team spirit and teamwork.
Can you describe what the situation was like for medical personnel from the area?
In the camp, protective measures were the same for everyone. Unfortunately, there were repeated cases of staff getting infected in the course of their private life, through contact with people outside the camp, through living with their families and so on.
How the local health workers’ situation developed after the crisis, bearing in mind the breakdown in the healthcare system, I cannot say.
Did you have to contend with people’s reservations, either in Germany or in the actual crisis region?
In 2014, the idea of flying an Ebola victim to Germany met with a lot of opposition. Up to then, such a thing hadn’t been an option — someone as ill as that was not to be transported across national boundaries. Fears ran high that the disease would be imported as a result. In reality, with the safety standards in operation and the medical knowledge about the disease and its progression, there was no danger.
In the end, both Hamburg politicians and the Federal Government behaved in an exemplary manner — and they had to give their consent before we could treat the infected WHO aid worker here.
While the care of the Ebola patient was taking place, the hospital carried on as usual. And in Eppendorf, the staff looking after him had volunteered for the job, taking on the burden by working extended hours.
On the ground in the crisis region, the stigmatization was often traumatic. Fear-stricken couples failed to look after each other, parents to look after their children, children after their parents. Survivors were frequently not allowed back into their village.
Have medical experiences been gained that are now of help in, for example, the Congo or Uganda?
It is still unclear what substances and medicine can be used to impact or halt the disease. However, vaccines have since been developed that were not available at the time of the 2014 crisis. They are already in use today in, for example, the Congo and Uganda.
Dr. Stefan Schmiedel
works as the senior physician in the Department of Infectious Diseases and Tropical Medicine at the University Medical Center Hamburg-Eppendorf (UKE).
His work covers, among other things, internal medicine, infectious diseases and tropical medicine.