Hanna Majanen summed it up best: "It is the things you do automatically that are difficult. People will touch their face, rub their eyes and bite their fingernails. These are the things you forget.”
As medical focal point for Médecins Sans Frontières (MSF) in Liberia, Majanen is well-versed in the rules and recommendations laid down by the organization for its frontline workers treating Ebola patients.
MSF, along with organizations like the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), has urged health workers to get as close as they can to a "zero risk" working environment. That means not only following strict procedures on wearing personal protection equipment (PPE) and ensuring maximum standards of hygiene in every aspect of work, but ensuring psychological back-up for those treating Ebola patients, and limiting rotations.
The US-based NGO International Medical Corps (IMC), expanding its Ebola activities in Liberia, provides a five-day pre-deployment training programme for recruits with a strong focus on PPE, emphasizing that IMC prides itself on taking care of the "wellness, safety and security of all individuals".
A history of frontline vulnerability
Health workers have always been among the fatalities in Ebola outbreaks, notably in Sudan and the then Zaire where the virus first came to light in 1976. But the West Africa epidemic highlighted their extreme vulnerability. According to WHO, in its Ebola Response Roadmap Situation Report for 8 October, some 401 health workers had contracted Ebola, with 232 confirmed or suspected deaths.
Serious deficiencies in isolation treatment and a shortage of resources took a heavy toll, creating risks for anyone in contact with Ebola patients. So, too, did failures to trace contacts of the infected and to ensure the safe burial of those who died.
Some of those mistakes are being belatedly rectified. But there is a huge gap between the ideal practices set out in WHO's guide for health workers Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation, with its emphasis on preparedness, containment and social mobilization, and the realities health workers have to confront.
Cleanliness is everything
In the absence of a known cure for Ebola, care to patients tends to focus on treating whatever infections are present, combating dehydration and balancing a patient's fluids and electrolytes. Enforcing basic hygiene standards has been an obvious imperative, both in medical facilities and in the community at large.
Along with strict injunctions on not touching the soiled clothes of patients, medical experts have constantly championed the use of bleach and detergent and the decontamination of surfaces. The most common sense practices, like regular hand-washing, have been made sacrosanct. Medical hygiene expert Terri Rebmann, advising on wearing PPE, noted that health workers tended to spend 10 minutes washing their hands, rather than the recommended 15 minutes, and urged them to use cold water not hot water (better for skin irritation), while remembering not to touch the faucet afterwards (risk of infection).
Majanen stressed that anyone working with Ebola needs to remember the infection possibilities are still there even when the day's work is over. "Ebola is everywhere," she pointed out. At ELWA (the MSF-run Ebola treatment centre) itself, the risks should be self-evident, "but we tend to be better at looking out for each other than looking for ourselves,” Majanen acknowledged.
Hence the need for another MSF staff to check someone has put on their PPE kit correctly: gloves, gown, hood, goggles, eye mask, boots, and removed it afterwards. It takes around 15 minutes to put on the PPE and the same to remove it. Goggles and gowns may be disinfected for further use, other items are for one use only, incinerated afterwards having been carefully disposed of. The PPE for Ebola is hot and cumbersome, best worn for only an hour at a time. Despite the drawbacks, Majanen admitted: "it's one of the places I feel most secure in." Despite the barrier between patient and a PPE-clad carer, Majanen said there was still a crucial level of intimacy. "Even touching someone when you have PPE on, it makes a big difference."
Searching for positives
Majanen said there were aspects of the work that gave her cause for optimism: the improving survival rates of patients at ELWA; the surprise recovery of a three-month old baby; originally diagnosed as Ebola-positive; the help and encouragement patients gave each other. "These are the things I try to hang on to." But Majanen also acknowledged that treating Ebola brought additional pressures she had not encountered before. "It is harder, it is tougher. There are more deaths. Even if you try not to have a relationship with the patients, it is sometimes impossible not to, particularly when they have been with you for some time."
According to Majanen, MSF still has to turn people away from its treatment centres on a daily basis. "It is very hard to turn down patients and to know also there are many people out there that don't have the possibility to come in." She warned against suggestions that the crisis in Liberia was somehow levelling off, particularly with the high profile US intervention. "We are hoping the attention Ebola is now getting will translate to something on the ground, but we are not seeing this get better. It still feels like it is going to be an endless story."