The only headstone in the group burial site just outside the Ebola treatment center in Guéckédou, Guinea, honors the grave of a Guinean nurse, one of the scores of local West African medical personnel on the front lines fighting the epidemic - and one of two dozen Médecins Sans Frontières/Doctors Without Borders (MSF) staff who have contracted the virus while treating patients.
Lost in much of the panic-churning coverage of the Ebola epidemic that has dominated the US press and the relatively detached numbers-gaming that marks much of the cooler international coverage ("Ebola Cases in Sierra Leone Show Sharp Rise," writes the Guardian this morning, while the AP leads with a dispatch from a Liberian town of 300 that has already lost 10 percent of its population) is a palpable sense of treating the sick - the at once basic and sometimes perilous care being administered by teams of local and international medical workers, up close and personal, to the overwhelmingly young men and women who have fallen ill in Guinea, Liberia and Sierra Leone, the three countries still struggling heavily with the outbreak.
It has thus been refreshing, moving and, at times, arresting to speak at length over the last several months with MSF nurse Carissa Guild about a hands-on effort at the community level in which colleagues can become casualties, and calm is as key to treatment as much of the modern medicine brought to bear.
"The vibe in the treatment center, in my opinion, should be pretty Zen," she said. "A lot of patients come in, but nothing is really an emergency - you're not going to save them with an American-style ER response. What you’ll save them with, maybe, is getting them comfortable, giving them dignity, making sure they don’t have pain, taking it easy and talking to them."
Warscapes editor Michael Bronner spoke with Carissa Guild via Skype last week, shortly after her latest round of nursing for MSF in Guinea:
Michael Bronner: You’re still being monitored – the 21-day incubation period of the Ebola virus. Where are you in the incubation stage?
Carissa Guild: I thought I was on day 20 today and tomorrow would be day 21, but it turns out this morning I had a call from my [Pennsylvania] Department of Health nurse who said that my 21 days start the day I land in the United States, and not the day that I had a last contact with an Ebola patient. So now my last day will be on Saturday.
MB: But you’re under what restrictions technically?
MB: So this is the third time now that you’ve been back from treating Ebola patients?
CG: It is, and it’s very different.
MB: We’re talking about the monitoring period. What are some of the differences?
CG: Well, the first time and the second time was pretty much the same. We had the rules then where I would take my temperature personally and I’d keep track of my 21 days personally, beginning from my last contact with an Ebola patient, and no one really seemed to notice. And if I had gotten sick, my strategy was that I would just call MSF and they would tell me what to do. But this time, I talk to the Department of Health several times a day.
MB: Let’s go back a little bit. Tell me a little bit about how you became a nurse and how you transitioned into international medicine and infectious disease.
CG: Well, I went back to school to become a nurse in New York about eight or nine years ago. We had a semester that you could spend abroad, so I spent time in Uganda focusing on HIV, malaria and tuberculosis, and I fell in love with Africa and knew that that’s what I was going to do. I had known about Doctors without Borders, and to work with them I knew that you needed to work in the United States for two years first, so I worked in the Bellevue ER for two years. And then, as soon as I could, I joined MSF [Médecins Sans Frontières/Doctors Without Borders] and have been doing it ever since.
MB: What was your first trip abroad with MSF?
CG: I went to Burkina Faso. The focus was malnutrition. It was a great little mission. You see a lot of really sick kids coming in, but the treatment is so quick and kids get better so quick that they’re actually pretty positive projects to work on.
MB: What was your first experience with Ebola?
CG: I was in Congo in 2012, which was a very different kind of project than [the current outbreak]. I think the most patients we ever had at one time was maybe 15 or 18, and we thought that was enormous.
MB: How did you make the decision to work with Ebola?
CG: In Congo, it sort of fell in my lap because I wanted to do a quick project and the timing was right. For Guinea, it was because I had that experience. I had planned on taking some time off after my last mission in Jordan, which ended in the end of March, and then [the current outbreak] started to come up in Guinea. There are not so many people, before this outbreak, who had seen Ebola at all, so anyone with experience was pretty useful to send to Guinea, especially because [local medical professionals] in Guinea hadn’t seen Ebola before.
Going to speak with a patient at the MSF Ebola center in Guéckédou, Guinea. Photo by Sylvain Cherkaoui/Cosmos.
MB: People, understandably, have some fear of Ebola. How did you learn how to navigate this environment?
CG: I was not actually that afraid in the beginning. I think I’m probably more afraid now, which I think is a pretty good sign. On my first mission, the nurse that I replaced was really good. I spent five or six days with her and I had a really good hand over in terms of the care she was giving to patients. Then, just being in Guinea for so long, I feel like I’ve been with some of the most experienced people in the world.
MB: I’m curious about your perspective having seen the current outbreak evolve over two tours in Guinea. What did you see when you first got there?
CG: I started in the middle of April. I was based in Conakry as the medical team leader, and I was there for two weeks, more or less, and in those two weeks we thought that the outbreak was finishing. A few people had left healthy. There was one patient who was still there, and he was about to go home healthy. We felt that in Conakry we had things under control, so I was sent to Guéckédou. And there, in the beginning of May, we also thought things were coming under control and had slowed down quite a bit. Then, by the end of May, we could see that it wasn’t under control at all, and Guéckédou started having more and more patients. And it was at this time we were also getting Sierra Leonean refugees coming in from across the border. Listening to their stories about what was happening on the other side of the border – end of May, beginning of June – we realized there was a big, big, big problem in Sierra Leone. When I left [at the end of my first trip], we had 30 or 35 patients in treatment and we thought was enormous. Now we have a hundred beds in Guéckédou, and it was nearly filled up this time when I left. I stayed in Guinea until the very end of June [the first time], and I went back in August.
MB: What’s a typical day?
CG: There’s always a morning meeting with the whole coordination group, which included the Department of Health in Guinea. We basically take a look at where we were, and then the day would start with treatment in the center. There would be an evaluation of all of the alerts of new cases, and we would send ambulances out to the towns to pick up these people or to go try to convince them to come in – if there were hot spots and we knew there were patients but we didn’t have access because we weren’t welcome. We would basically work with the authorities in Guinea to try to convince them to send the patients. Once we got the OK that the community was happy to have us, we could send our ambulances to go pick up the patients. We also dispatched the team of “contact tracers” every morning—
MB: What does a contact tracer do?
CG: Contact tracers create a list of people who had physical contact with an Ebola patient while that person presented with symptoms. They go to the villages every day for 21 days to personally check on all of these contacts, making sure they feel well, with the purpose of identifying and isolating cases in the community as fast as possible after the onset of symptoms, and thus as soon as they become contagious. Then there is also the team of “health promoters” who would also be dispatched. They teach local communities by explaining what Ebola is and how to avoid transmission.
MB: The people going out into the community, the local staff – would they be in protective gear?
CG: Not for contract tracing, and not for health promotion. We weren’t taking people’s temperature, so they weren’t getting too close to patients, and there were distance rules. If I went as a medical staff for an outreach team, I would go to the community to see a patient, and if the patient could walk and talk, we’d ask them to come outside of their house. You keep your distance. You chat with them and see if you think they are a case or not. If they can walk and talk, no one needs to really get dressed up at this point, and they can just basically get themselves into the ambulance. If they can’t walk anymore, we would have to get dressed up in personal protective equipment and get them on a stretcher and bring them into the ambulance that way. Then, if the patient tested positive, the same team would go out and decontaminate the house. Any time you entered a house or a structure that had had an Ebola patient, you had to get dressed in that personal protective equipment.
MB: And the ambulance drivers were wearing protection?
CG: No. The ambulances were mostly pickup trucks, so the back was very open and the back had no contact with the front. We had a bit of flak in Guinea because we were using pickup trucks. They thought this was like transporting animals, but we actually chose those specifically because they’re really easy to decontaminate when we drop the patients off. You can just take off the mattress, you spray the whole pickup bed – there are no nooks and crannies – and then put a fresh mattress in.
MB: We first spoke just after you’d just gotten back from your first trip to Guinea, and you mentioned that stigma and denial surrounding Ebola were big factors in the communities that had seen cases. How has that changed, if at all, as more and more people are getting sick?
CG: In the prefecture of Guéckédou, where most of the cases were coming from the first time I was there, there was a lot less stigma. In the prefecture next door, there was the same exact stigma and problems and disbelief as we saw in Guéckédou six months before. In Wome, not too far from where we were, there were the eight health workers who were killed [by angry villagers]. So it’s still a big problem. At the same time, you could see quite clearly how Ebola does its own health promotion and education. When Ebola first hits a town, people...wait and they watch how many people get sick – how the virus is transmitted – and they see that one person dies, then the person taking care of that person becomes sick and that person dies, then person who cleaned the body becomes sick. Basically, after a week or two weeks or three weeks, the population starts to see and understand how it works.
MB: You mentioned that in Congo you saw family members come in sick, one after the other. Was it the same in Guinea?
CG: Yeah, it was similar. One morning, I was talking to a family member of a patient. We were standing outside one of the tents. His wife was inside. I asked him to explain how Ebola came to his village, and he went through the people in the tent – every person in the tent – and how they got infected and who infected them and how the virus first came into the village from a person who went to Liberia to visit family and who had come back and had died. He went through the whole story, which was incredible.
MB: Peter Piot, one of the investigators who discovered Ebola in 1976 and has been at the forefront of Ebola and HIV research, said about this outbreak that it’s not moving linearly like it usually does, but that it’s hopping around. Does that resonate with what you’ve seen?
Patients are helped into the Ebola case managment center in Guéckédou, Guinea. Photo by Julien Rey/MSF
CG: People who are getting sick are moving, and dead bodies are moving, despite the fact that we’re saying not to move around. I looked at one patient’s pathway, which began in the middle of Sierra Leone. He went west in Sierra Leone and he made it to Conakry [in Guinea], then he continued on through all of Guinea to end up in Guéckédou. He ended up dying before he made it to Guéckédou, and he took public transportation that whole way. Another cluster started in a prefecture called Dabola, and we think it started with two people – an older couple who died in Conakry, and whose bodies were then sent on a two day journey to get back to their home village to be taken care of and buried there. So as far as hopping around, you can see that one person can infect people in, say, six places.
MB: How long does Ebola survive in a corpse?
CG: Corpses have the highest viral load, and they’re leaking quite a lot, so they are particularly dangerous…There was a certain point at which our treatment center stopped moving bodies [to their home villages for burial]. It started to be a problem, because we had a lot of people coming from Sierra Leone. So the government basically gave us a cemetery next-door to the treatment center and we would bury everyone in this place.
MB: The WHO has said that the number of new cases in West Africa is doubling every 20 to 30 days – or roughly every three weeks. Does that reflect what you saw in Guinea?
CG: When I arrived in Guinea on my second mission, there were a lot of patients hospitalized. And then there was a little bit of a decline in the number of patients that we were getting. When I was leaving it was going way back up. We were starting to question whether we were going to have to turn people away, as they were doing in Monrovia [Liberia]. We were getting patients who were coming from a very far away, and it seemed like when someone would get sick in a particular town, the town would wait until they were pretty sure that this person had Ebola – and until maybe there were several local people sick – and only then put them in an ambulance and send them to Guéckédou. This gives me a lot of fear that there are a lot more [cases], because you tend to take this as like a small sample of what’s happening in their village.
MB: So, at the time that you left this last time, did it feel out of control?
CG: In Guinea, it feels way more out of control than it’s ever felt. I have a bit of a fear for them, actually.
MB: So what is needed most there?
CG: There needs to be training – for everyone – so that cases are identified earlier. And they need more treatment centers where those patients can go and stay isolated to protect their families. Right now, cases are getting identified very late. There are still health care workers who are dying. They should have the equipment that they need to protect themselves, and they should know how to protect themselves. If there was a vaccine, that would be really, really useful.
MB: You said that things were really on an upswing as you were leaving. What are the emotions of deciding when it’s time to leave, and actually leaving?
CG: I was very sad to leave the team, but I was also very tired, and it seemed like we were entering into a different phase of the outbreak. We had basically arrived to the point of having something like 99 beds filled, and we were able to work it and take care of those people and have a strategy for it. But now it seemed like there was something else that was going to have to happen – like another huge burst of energy to get to the next level of what we were doing – and so, for me, I was at the point of being too tired to do that. There are a lot of hard decisions to be made at this moment. Decisions about who are you going to treat. Decisions about how much to protect the staff versus treating the patients. I think it’s very difficult for the national staff at this point, because they’ve been working for seven months, and it’s basically for them the burst of energy after burst of energy after burst of energy, and seeing a lot of stuff that most people have never seen in their lives and will never see.
MB: And when you say tired, I’m sure it’s physically exhausting, but you’ve also seen a lot of patients die.
CG: It’s physically exhausting. It’s emotionally exhausting. Our psychologists would basically do all the announcements of all the dead people every day and organize the funerals – so they’re doing this for seven months, and we have between two and 12 people who die every day. So that’s 12 families you have to inform that their loved one has died. That’s 12 funerals you have to organize. It’s just really draining on the staff. We also had national staff members who got sick while I was there, which is very draining on everyone because it’s really emotional and it makes you question a lot of things. Also, some of the national staff were stigmatized in their communities, so then even their home life got harder. You see a lot of suffering in Ebola. The patients suffer a lot.
MB: A painful way to die.
CG: It can be. It’s also emotionally painful for them. It could be a mother who contaminates her child, and then two days later this person is suffering and she looks over and her family member comes in and she knows she is responsible for infecting this other person. And then she might have to watch the family member die before she dies or gets better. It’s really hard. You have people coming to take care of you who are dressed up like space men who are covered in chlorine and dripping wet. You can’t be touched by anyone because you’re dangerous to people. It’s trying emotionally for the patients.
MB: You said at the beginning that you’re more afraid of the virus now than you were when you started…
CG: In the previous outbreak, in Congo, I had seen Ebola come under control, and I could look at a chain of transmission and I could basically see how it was playing out: If you could just get to those people, it was easy to think that it could possibly end. This time, because it’s so big and it’s affecting so many people, and it’s not linear anymore, it’s just on such a bigger scale.
MB: It must have been strange coming back to the United States and seeing the way that Ebola has covered here.
CG: It’s kind of crazy. And I have to say that, since I’ve been back, it’s been a little bit disheartening. Every time I turn on the TV, the big headlines are all about Ebola, and I think that I could probably count on one hand how many actual articles about West Africa. It’s all about quarantining health care workers when they come back. It’s all about fear in America – fear of X, fear of Y. And, sure, it’s a big deal when an expat gets sick, and it’s a big deal for a country when someone in your country gets sick. I understand that. But compared to the 10 thousand people who are sick in West Africa? For me, it seems like the news has really kind of gone a little bit…
MB: What are the most important things for the public to know about what’s happening there?
CG: There are the statistics about Ebola and how terrible it is in West Africa, but I think what the public is forgetting – even for the few patients [in the US] – is that these people are human beings. And they’re all human beings that are young – 30-year-olds who go from healthy people to dead in two weeks. It’s destroying villages there. Their economies are going to start breaking down. I think there needs to be a lot more help, because it takes a lot of resources and a lot of people to make it happen. I think there could be a better push in the news media to try to promote how we can get more people to go and to help.
MB: More doctors and nurses, you mean?
CG: Yes. The US has sent three thousand troops over to West Africa – I think they’re going to build 17 treatment centers. That’s great, but anyone can build 17 buildings – that’s not treating Ebola. Treating Ebola means training people to work in those buildings, and finding national staff to go work in those buildings, and finding expats who would go work in these buildings. In Guinea, for example there is one doctor for every nine- to 10 thousand people. We need more people going.
MB: What kinds of doctors and nurses are most qualified do this work?
CG: I think anyone, really. The care itself is not that intense. The care, basically, is fluids – very easy care. Psychological support, food and water and Tylenol. I think mostly you just need to be relaxed. The vibe in the treatment center, in my opinion, should be pretty Zen. A lot of patients come in, but nothing is really an emergency. What you’ll save them with, maybe, is getting them comfortable, giving them dignity, making sure they don’t have pain, taking it easy and talking to them, and not just trying to pop IVs in and going crazy and getting stressed out. They are in a place that is so stressful, with all of these space men walking around. They need calm people to take care of them, just to be with them.
MB: Do you think you’ll go back again?
CG: I just got a new job to work in Paris with Doctors without Borders as an infection control person for Ebola contexts. I’m sure I’ll take visits back to the field. I’ll be around.
MB: Thank you for doing this.
CG: Of course.
Michael Bronner is Editor-at-large for Warscapes.