A scar that runs deep

Although Ebola Virus Disease (EVD or Ebola) has not been making the headlines since its major outbreak in March 2014, it still continues to claim lives, particularly in the West African nations of Liberia, Guinea and Sierra Leone. Médecins Sans Frontières (MSF), an international humanitarian-aid NGO (also called Doctors Without Borders) has been working in West Africa to help contain the outbreak. Madurai-based Dr Kalyani Gomathinayagam, a practising general physician in rural Thiruvananthapuram for over 25 years, began her MSF career in 2010 as an emergency doctor in Haiti, post the earthquake followed by stints in Ivory Coast, Chad, Democratic Republic of Congo and more recently in Sierra Leone and Yemen. Excerpts from an interaction about her challenging and emotionally-taxing mission:

What inspired you to join MSF?

MSF provides medical care to those who direly need it in the most tenuous circumstances. The dedication and independence along with neutrality in provision of acute medical care inspired me to join the organisation.

It amazes me how people muster great fortitude and resilience when faced with the most trying situations. I have been to places where they have never seen a doctor. You will be surprised by their pragmatism. These experiences make you humble.

How difficult is it to fight Ebola?

It is denial in the beginning. The fact that patients would never be able to see their loved ones again after they were taken in an ambulance is scary. So, until health promotion activities were successful, people would hide the fact that they are sick and inform only in the end when nothing much could be done. The stigmatisation of having lost a family member to Ebola or being a survivor was complex and not easily allayed as people believed they were witches and ostracised them. With its high mortality and morbidity rates, Ebola not only affects one at an individual level, but it also tears apart the very fabric of the human society in the most inhuman way!

How does this change the dynamics of the doctor-patient relationship? 

Due to the Personal Protective Equipment (PPE) worn by the medical staff and physical limitations on account of high infectivity of Ebola, the regular doctor-patient relationship is skewed. Normally, a face-to-face interaction, which helps the patient to a great extent is not possible in PPE — where only the eyes are visible and voice heard. The patient, if too sick, is seeing only the doctors, healthcare workers and even his family in full protective gear, which demoralises and scares him.

The healthcare worker to bed ratio for Ebola is very high — for a 80-bed centre, one would need around 1250 staff (in hospitals and for outreach activities). Apart from the medical team, the hygiene team comprising high-risk and low-risk sprayers, cleaners, laundry, the burial team, the outreach team, the health promotion team and the psychosocial team. The logistics were drawn from all strata of society to keep the activities going around the clock.

What are the safety procedures you had to follow before heading out on the mission?

All expats going on Ebola missions with MSF were briefed thoroughly about risks involved, encouraged to get all vaccinations done and report any minor symptom or accidental exposure and were mandatorily asked to be on malaria prophylaxis as the country was endemic to malaria. During the mission, we were explained to keep a distance of two metres at all times with patients, national and expat staff and also not to shake hands, hug or go to social gatherings or places.

Although it was for our own safety, it was hard. Every action that was to be carried out for the patient had to be discussed with the team beforehand and the time we hand in the PPE was only for an hour. We always went in pairs to keep a lookout for the other person who was doing the procedures. If we could not complete the actions, the next team would have to complete it. Wearing the PPE would take us around 20 to 30 minutes. Once the mission was completed, we had to agree to undergo a self-monitoring period of 21 days to be completely sure that we had not been infected and thereby, pose a public health threat back home.

What were your high and low points?

One of the high points is when a patient recovers from the Ebola virus and when you see the happy faces of those who get a negative test result. I remember one time when I had to gesture to an elderly lady (as she did not understand the local language) that she was negative for Ebola and her happiness was palpable. Another incident I remember clearly was when my patient recognised me by my voice, despite the ubiquitous PPE and asked me where I had been, as I had not come in for the morning rounds.

One of the hardest things is losing a patient. I remember a young child had tested positive for Ebola after an initial negative test. He met his father and spoke to him briefly before he turned weak and took a turn for the worse. There was nothing we could do, despite trying everything.

Are we prepared to deal with the Ebola threat now?

After getting to the state of near zero in the three worst affected countries (Guinea, Sierra Leone and Liberia), the new cases in Liberia are disheartening. However, with the lessons learnt, we can beat this virus. Complacency in our activities will be a costly one and we need to strengthen our surveillance and monitoring system to break the chain of transmission. We also need to pool in our resources globally to put in an effective basic healthcare structure in these countries, which have lost almost one third to half of its healthcare workers. The donors and ministries of health have to work hard together to identify areas of priority to stem the infection flowing through low standards of healthcare set-ups. But most importantly, it is necessary to provide a comprehensive health package to the Ebola survivors.