Tuesday, February 17, 2015

Debriding a large tropical ulcer

At 14 years old, patient did not qualify for free govt care.  As with many of our patients, he was not able to afford treatment and a small medical issue turned into a threat to life and limb, due to lack of care.

Ebola and other medical care work update

Working on Ebola surveillance/treatment/decon, and have transformed a basic maternity/infant care clinic into a full-service free primary care/ER/maternity clinic in the mountains of E Sierra Leone. Starting to see patients who have walked all day to get to us. Malnourished kids, typhoid, ebola, infectious diseases, impressive fungal infections, tropical ulcers, and gangrene.  Compound tib-fib yesterday (fortunately there was a well-known local bone-setting herbalist available to work with), great debate over whether to amputate a big toe if govt surgeons are not avail due to Ebola... Just freed a 7 yr old from having 3 seizures/wk with a $2/month script.

Sunday, February 1, 2015

Ebola: Dispelling Myths

Last night our expat team joined some local folks for beers at a friend’s place.  We sat outside until late at night, sipping cold Guinness, with Freetown’s mix of thrumming generators, blaring horns, and tropical bird calls filling the warm night air.  In an effort to halt the spread of Ebola, the Sierra Leone government has imposed a curfew on motorbike taxis and shops (with the exception of pharmacies): no business after 1800 on weekdays, or 1200 on Saturdays.  So the former patrons of small beer stands along the streets have shifted to smaller home-based night-time gatherings.
This was a worldly bunch, and we swapped tales of shenanigans in places ranging from Kenya, to India, from Afghanistan to Antarctica.  Most present had traveled extensively for work or military service. 
Eventually, as it often seems to do here, the talk turned to corruption and exploitation.  The people of Sierra Leone, a small country of 6 million, rich in diamond-bearing kimberlite, iron ore, uranium ore, and other mineral resources, should enjoy a relatively comfortable and prosperous existence.  Instead, the vast majority of Sierra Leone’s wealth is funneled out of the country by international firms, or is sucked up by a small, corrupt local elite class.  Sierra Leone’s living standard is often contrasted by people here  with conditions in South Africa and Botswana.  In spite of many decades of intensive mineral harvesting, Sierra Leone remains one of the world’s poorest, least developed countries.  Many rural areas have no road access, no healthcare, and almost no government support.  In the decade since Sierra Leone’s incredibly brutal, diamond-fueled civil war, millions of dollars worth of international developmental efforts has done little to change this.  It was in this context that Ebola spread so rapidly once it entered Sierra Leone.
On a positive note, Sierra Leone has wealth that goes far beyond what lies under its soil.  Having read about the terrible things that happened during the war here, for many years I have subconsciously  pictured Sierra Leone as a dark, angry, cruel place.  My last personal experience of a (still somewhat active, low-level) recovering conflict zone was Bougainville and the mainland of PNG.  While I met many friendly, good, and kind people in PNG, in most towns and cities an oppressively dark, angry mood hung in the air.  Smaller islands and villages were often peaceful and pleasant, but in towns things always seemed just about to erupt into violence.  And several times they did.  
So, subconsciously, I expected a similar mood of repressed violence in Sierra Leone.  So far, that expectation has been very mistaken.  In spite of what, to me, seem like constant and unforgettable reminders of the war… a generation that missed schooling, the very common sight of people (often beggars) who have had one or both hands amputated by RUF or other military forces- Sierra Leoneans universally assert that people have generally gotten over the war and moved on.  While people are often willing to talk about their experiences, reference events of the war, and relate items such as Foday Sankoh’s imprisonment and death (with a bit of justifiable relish), on an emotional level this really does seem to be true- the people I’ve spoken with in Freetown have gotten over the war and the anger is gone.  Far from gloomy and dangerous, Freetown has one of the safest and friendliest atmospheres I’ve encountered in a developing world city.  There is certainly anger here, but it seems to be mostly directed in potentially constructive directions, such as against the slowness of the EVD response, government corruption, and the funneling of resources out of the country. 
One of the best, most promising things about Sierra Leone society is its religious tolerance.  At a time when religious-based violence seems to be erupting in the rest of the world, in Sierra Leone Muslim and Christian communities intermingle in harmony.  While the radio news talks about IS, Boko Haram, AQ, Yemen, Charlie Hebdo, and anti-Muslim protests in Europe, in Sierra Leone Christians greet Muslim friends and neighbors with “Salaam Alaykam”, and Muslims thank Christians with “God Bless”.  In the evening Muslims and Christians mingle freely over coffee or drinks, and In the newspapers Muslim and Christian advice columns run side-by-side.  Local friends note proudly that even during the war, vicious as it was, attempts to divide communities based on religious affiliations were not successful. 
Part of the reason for this religious tolerance is that Islam and Christianity in Sierra Leone are overlain onto an older set of indigenous beliefs and very intact social power structures, such as secret societies.  Nearly every man and woman in Sierra Leone is initiated during adolescence into a secret society – “Poro” for men, “Bundu” for women.  These societies are a powerful force in Sierra Leone.  Upcounty (in rural areas), where government presence is thin, the Poro and Bundu provide key community services such as cleaning and maintenance of communal lands and buildings, and civil defense during the war. 
One topic that we all spent a long time discussing last night was Ebola rumors.  Some of these may seem pretty far-fetched to Westerners.  Upcountry, western medicine is often unavailable.  When available, basic medical services may be offered by a competent practitioner.  Or they may be offered by a traveling profiteer, with minimal training, who passes off placebos as antibiotics, or worse.  Government presence in such places is often minimal, and the main contact with foreigners is with those involved in reaping the country’s natural resources, with minimal resultant gain for local people. So naturally, people may have limited faith in westerners and western medicine, and instead tend to rely on local spiritual/natural healers who have established reputations in the community.  Often, illnesses and deaths are ascribed to some sort of transgression on the part of the sufferer, or to witchcraft.  Part of the upcountry Mende beliefs is the existence of a nocturnal, technologically advanced world of witches.  One persistent upcountry rumor blames Ebola on the overflight or crash of several witch airplanes into the remote forests of northern Sierra Leone, resulting in the curse of Ebola spreading there.  
The plane rumor is generally disparaged by educated people in Freetown.  But Freetown has its own Ebola rumors.   Like some people in the US, some people in Freetown wonder whether Ebola is airborne.  This rumor is pretty easy to dispel by going into the nature of PPE used for Ebola, and contrasting Ebola’s spread with the spread rate of diseases that are actually airborne, such as flu, TB, SARS, etc. 
Others rumors are trickier.  And the more you think about them, the more you realize some could be pretty easily to rationally wonder about, if you were coming from a Sierra Leonean background.  For example, we were asked if Ebola could have been created in a lab, as a weapon, and released here accidentally, or as a test.  This may seem highly implausible to the average American, but imagine that you live in Freetown. 
You live in a country that should be the Switzerland of West Africa.  Instead, most of the wealth is funneled out of the country by forces you can’t control.  How far-fetched would one more form of exploitation seem to you in that situation?
You have a fairly free press and BBC radio, but limited access to the internet.  Much of the real news in the country is spread through acquaintance networks.  Much of real business in your country, and real actions of the government, go on behind the scenes.  You tend to trust information from acquaintances more than the official line.  Perhaps you have a trusted acquaintance or two that believes Ebola is airborne, or made in a lab, and they make convincing arguments to support their theory.  You don’t have a computer sitting in your living room or a mental database of trustworthy online scientific information resources to consult on the pathology of the virus, so it’s up to you to evaluate the soundness of the arguments your friend is making.  Your country lacks the sort of large, powerful, trusted civil society and legal rights organizations that can help to provide power checks on government in, say, the US.  Sometimes bad things happen, and there isn’t always accountability afterwards.
You know that biological weapons accidents have occurred in the past, for example in the Soviet Union, and that there were attempted cover-ups.
Your friends are asking why the US military is putting so much money into the Ebola response in Liberia. 
Unlike in recent US history, unbelievably terrible things have happened on a large scale in recent Sierra Leone history.  This stretches the boundaries of plausibility a bit.
You are told that this is not a new virus, that it’s the same one that’s been studied for decades in central Africa.  But you know that it has never spread as a large-scale epidemic before.  Why now?
You are told not to eat bush meat, but you know bush meat animals in West Africa have been linked to central Africa by a corridor of rainforest for centuries.  Bush meat has been eaten for centuries, why has Ebola migrated to Western Africa only now?
You see your country’s top doctors, CEOs of banks, and other powerful people dying.  The death rate of infected in your country is 60-70% even with treatment.  Yet, when westerners are infected, they are transported overseas and, mysteriously, they all survive (except 2 elderly Spanish missionaries).  This could easily be misinterpreted as proof of a secret cure.  Now, to me, this is simple racism and selfishness.  But it is not necessarily that easy to convince a Sierra Leonean person that no, there is no secret, proven cure, and yes, the world is just simply too selfish to treat non-citizen Ebola patients in developed-world medical facilities.  The world is spending massive amounts of money on fighting Ebola, but the facilities that actually save lives are almost all standing by, empty, in the developed world.  Sierra Leone is a country that absolutely can’t afford to lose medical personnel.  For example, it only has lost 20% of its surgeons to Ebola; leaving 8 surviving surgeons to treat a country of 6 million.  Only one of these is under 60 years of age.  The doctor I’m staying with is nearly 80, and would like to retire, but is delaying retirement because he is so badly needed.  Sierra Leone docs who risk themselves to treat patients should be guaranteed a quick evac to Emory et al, for best possible treatment.  Its hard to sit down with people who are taking terrible risks to help their countrymen and explain why that hasn’t happened.

To my mind, the best way to dispel such myths is to sit down, share views, and have a respectful, open discussion with those individuals who the community looks to for wisdom and information.  Some of what I feel are our most effective arguments against Ebola rumors:
Describing the virus itself in layman’s terms helps people understand how to avoid it, i.e. it’s a bunch of genetic code (like the letters in a book) wrapped in a rather thin layer of fat… a virus’s only job is to inject that book of code into a human cell, so that the cell is forced to copy it and make more viruses… the Ebola virus’s layer of enveloping fat can be destroyed by thorough washing with soap, bleach, or alcohol hand cleaner, and the genetic code that’s left over falls apart.  Shred a book and try to read it… you can’t.  Ebola doesn’t persist in air or in the environment because it can’t hang in the air like TB does, and on a surface sunlight and air destroys it within 15 min- to a few hours, depending on amount of contamination and environmental conditions.  Those who are ill with Ebola don’t tend to shed large amounts of virus until they are visibly very ill, with limited mobility, or deceased.
Explaining the oldness and relative genetic stability of the Ebola virus (in layman’s terms)
Ebola’s inefficacy as a weapon (not readily dispersable as an aerosol, doesn’t survive transport, doesn’t endure in the environment, the fact that there is no cure, etc)
Human decency - The EVD epidemic has been so bad (21,000/+ infected) that if it was intentionally caused, at least one of the people involved in such a project would probably have been guilt-stricken enough to come forward with concrete evidence.  That kind of revelation would be a NYTimes front page piece, not a National Enquirer piece.  Same story if there was actually a large stock of a proven cure available.
Describing central African cultural traditions which have limited the scale of Ebola outbreaks there, versus some West African traditions which have served to spread it here
Thoroughly describing treatment procedures in the US and the fact that even those treated in the US get terribly ill before recovering
Describing the limitations of potential cures under development
Sharing the fact that the first vaccine test groups were American volunteers in the DC area (which a couple of our team members offered themselves as volunteers for), and Canadian volunteers in Canada.  Describe vaccine testing process and projected available doses.  With encouraging test results and millions of doses already produced, the vaccine (probably the ultimate large-scale EVD solution) seems to be a much less prominent part of local discussions than are potential cures (not going to be a large-scale solution for West Africans- especially in remote areas- any time soon, if ever).

2006-2008 USAMRID/Kenema Study Finds EVD Antibodies in 8% of Sierra Leone blood samples in test pool


Thatch temporary isolation unit outside of the clinic