Ebola | Doctors at breaking point: ‘This constant feeling that the boat’s sinking’

A burial team in protective gear carry the body of woman suspected to have died from the Ebola virus in Monrovia, Liberia

At 3:30 a.m. in the world’s biggest Ebola treatment center, Daniel Lucey found the outbreak reduced to its essentials: patients lying on mattresses on the floor and vomiting in the dark, visible only by the wavering flashlight beam of a single volunteer doctor.
“I don’t see a light at the end of the tunnel,” said Lucey, a physician and professor from Georgetown University who is halfway through a five-week tour in Liberia with Medecins Sans Frontieres, the medical charity known in English as Doctors Without Borders. “The epidemic is still getting worse,” he said by phone between shifts.
That’s an increasingly urgent challenge for MSF and the global health community. As fear spreads in the U.S. over transmission of the virus to two nurses in a modern Dallas hospital, the main fight against the outbreak is still being waged by volunteers like Lucey half a world away.
MSF has been the first – and often only – line of defense against Ebola in West Africa. The group raised the alarm on March 31, months ahead of the World Health Organization. Now, after treating almost a third of the roughly 9,000 confirmed Ebola cases in Africa – and faced with a WHO warning of perhaps 10,000 new infections a week by December – MSF is reaching its limits.
“They are at the breaking point,” said Vinh-Kim Nguyen, a professor at the School of Public Health at the University of Montreal who has volunteered for a West African tour with MSF in a few weeks. MSF has already seen 21 workers infected and 12 people die, and “there’s a sense that there’s a major wave of infections that’s about to wash everything away,” Nguyen said.
The story of how a relatively small, decentralized group like MSF came to lead the response to the world’s biggest outbreak of Ebola began 43 years ago in Paris. Alarmed by war and famine in the Nigerian secessionist state of Biafra, 13 doctors and journalists created an emergency medical response organization that could work around the world.
The founders imagined a global version of France’s emergency medicine system, according to Peter Redfield, a professor at the University of North Carolina at Chapel Hill who published a 2013 book about MSF. The group has since opened offices in 28 countries, and in 1999 it won a Nobel Peace Prize. The money was used to study neglected diseases.
“They have 40 years of experience dealing with the kind of situation they’re in now,” said Renee Fox, an emeritus professor of sociology at the University of Pennsylvania who published her own book about MSF this year.
MSF views part of its job as “temoignage,” or bearing witness to injustice, Fox said. The organization has clashed with global pharmaceutical companies over the price of medication in developing countries, and this year it spoke out about chemical weapons attacks in Syria. In West Africa, it called for a broader global response before the WHO was willing to acknowledge an emergency existed.
“People did not listen,” Fox said.
WHO Director-General Margaret Chan said in an Oct. 17 interview that the agency’s response may not have matched the scale and complexity of the outbreak.
MSF was already in Guinea when the Ebola outbreak began. A Swiss team doing malaria control in the town of Gueckedou, near the borders with Liberia and Sierra Leone, got a letter from Guinea’s Ministry of Health on March 12 detailing an illness that had struck eight people, including a doctor who died after caring for a patient from Gueckedou. MSF dispatched researchers to take blood samples, case histories and symptoms, according to Hugues Robert-Nicoud, an MSF emergency program manager.
They initially suspected Lassa fever, a disease common in the region. It took a week to organize safe transportation of the blood samples, first to the Guinean capital in Conakry and then to European labs. On March 21, the Pasteur Institute in Lyon, France, said the mystery disease might be either Ebola or Marburg, a similar virus.
“I dropped my pen and thought, ’This is trouble,’” Robert-Nicoud said. The lab confirmed the worst: Ebola.
On March 23, the WHO posted the confirmation on its website. A week later, MSF issued a statement citing eight cases in Conakry and calling the outbreak unprecedented. The WHO didn’t declare Ebola an international public health emergency until Aug. 8, more than four months after MSF’s warning.
In March and April, MSF was able to follow patients and everyone they had come in contact with, what’s known as contact tracing. While MSF has sent almost 300 foreigners to West Africa to fight the epidemic, and has hired about 3,000 locals, it can no longer do effective contact tracing due to the exponential rise in cases, Robert-Nicoud said.
“There’s a change of scale in this epidemic every two weeks,” he said.
When he was in Monrovia at the end of September, Robert-Nicoud said the ministry of health told him there were only 12 ambulances to serve a city of 1 million people, where traffic jams can delay delivery of patients to treatment centers by two hours.
“It’s this constant feeling that the boat’s sinking,” Robert-Nicoud said. “You try to plug the water that’s coming in, but the holes are everywhere.”
Meanwhile, the treatment centers promised by leaders in the U.S. and Europe have been slow to materialize, and little has been said of medical personnel to staff them. About 500 of the 4,000 U.S. military personnel authorized for the mission are now in Liberia to build at least 17 100-bed treatment centers, provide logistics and train health workers, the Pentagon said yesterday.
The U.S. has so far committed to sending 65 medical staff from the Department of Health and Human Services who will provide direct patient care at a 25-bed hospital in Monrovia dedicated to treating infected health workers. The facility is scheduled to be completed by Nov. 5, said Pentagon spokesman Army Colonel Steve Warren.
Cuba has sent 165 health professionals to Sierra Leone, and China is providing 174 medical staff in the same country, according to the WHO. While more than 600 U.K. National Health Service staff have volunteered to head to Sierra Leone, it’s still unclear how many will be deployed.
In Monrovia, Georgetown volunteer Lucey’s Elwa3 Hospital consists of 10 tents, stifling in the tropical heat, with corridors of orange netting separating the definitely sick from suspected cases, the dangerous from the safe.
Some 600 Liberian citizens work with a rotating team of international doctors, nurses and logistics experts. Still, the enveloping suits required to protect caregivers from infection are so hot that doctors must limit their shifts to just 45 minutes.
Lucey said MSF doctors rely instead on recovering patients for help. Infected adults care for other people’s children; one 20-year-old man took over diaper changes for a sick three-month-old.
“Every day we have deaths,” Lucey said. “Every morning you get up at 6 a.m., go to sleep at 11 p.m. Meetings in the morning and meetings at night, and you work, work, work until you can’t work anymore. Then you get up in the morning and do it again.” Makiko Kitamura and Naomi Kresge, Bloomberg