Sunlight in the Shadows
March 28, 2015
Freetown, Sierra Leone
S. Todd Stolp MD
A new life was born at the Holding Center last night. A 30 year old young lady presented to a local hospital after she experienced an event called “escape of liquor” while at home. This phrase turned out to be a much more poetic reference to the much clumsier “broken bag-of-water” or more text-booky “ruptured membranes” that every mother experiences upon releasing her progeny from an aquatic existence inside her body. She had been advised by the outpatient screener at a hospital to go home and return later. Accordingly, she went home and a day later she began to experience abdominal pain – that is, a series of abdominal pains – and fever. The pains were, of course, labor and the fever was her ticket to the Holding Center for patients suspected of being infected with Ebola. Happily, she delivered a 5-plus pound infant with a lusty cry and immediately began attending to motherly duties. Despite the fact that the birth occurred in a dark, chlorine-soaked concrete cell, the joy of the moment was captured by the brightly colored organic patterns on cotton fabric – a garment called a “lappa” – that seemed to illuminate the dark as the cloth draped over the new mother and her baby.
Our major role at this point in the epidemic is to assure that patients who meet the case definition for Ebola receive the best care possible under conditions that are safe for the care team while the lab runs a PCR test to hopefully rule out Ebola Virus Disease (EVD). Because patients infected with this nasty virus can smolder with fever and symptoms for up to three days while still testing negative for the illness, assurance that any patient is not infected requires that they test negative after either having been symptomatic for three days or after having had a previous negative test at least three days earlier. Once the disease is ruled out, then patients can return to the mainstream health care process to see if they can find a provider willing to see them. And that is no easy task.
Once we have convincingly ruled out Ebola, each patient receives a card indicating the date that we determined that they were found to be Ebola free. Regardless of this assurance, doctors and facilities are often unwilling to see such patients because of concern for a missed diagnosis of Ebola and because of well-told stories – allbeit of very rare instances – of patients having been cleared from Holding Centers and subsequently developing outright Ebola Virus Disease. Much speculation churns about the cause of such events, one being that patients may occasionally become infected while they are under isolation at the Holding Center. This, of course, is no more an indictment of Holding Centers than the occasional reaction to an immunization is an indictment of vaccination campaigns for childhood illnesses. Nevertheless, it drives efforts to meticulously curtail any possible sources of transmission within the Centers themselves.
Another theory about the rare instance of a person cleared for Ebola subsequently becoming infected may relate to the fact that certain risk factors which may have precipitated a patient’s first Holding Center stay – a confirmed illness in a family member, work in a morgue, working in health care – may continue to act upon these people, raising the likelihood that potential sources of infection continue to be present in their lives.
Particularly during the tapering tail of any epidemic, the transition back to “normal” health care operations is very tricky. It is even trickier when the disease is as fickle and as lethal as Ebola. Epidemiologists usually define resolution of an epidemic as the passage of time equivalent to two incubation periods for the pathogen in question. For Ebola, with an incubation period of up to 21 days, this means we are looking to achieve 42 days without a single case of Ebola. Until that happens, and perhaps for a period of time afterward, potential cases will need to be treated as true cases while undergoing the necessary testing in order to prevent transmission to health care workers or to other patients. There are many forces that encourage complacency, not the least of which is empathy for the ailing patient, such that the most important time for renewed vigilance in managing potential patients is as the last flames of an outbreak are being extinguished.
It is more than apparent that the population will have vivid memories of the 2014 West African Ebola Epidemic. People on the street greet each other by putting their hands over their hearts or by touching elbows, but not by handshakes. As one enters markets, the ever-present aroma of chlorine permeates the air and handwashing stations abound. Infra-red thermometers blaze away, recording forehead temperatures as people enter high risk areas to assure that febrile patients do not comingle in the crowd. All of these adaptations will be slow to subside, just as airport security was forever changed by the events of 9/11/2001.
Assuring that a patient can pay for the requested services remains a formidable task when seeking to refer a patient cleared of Ebola to an outside caregiver for care. This latter endeavor is not easy. Without money and devoid of a real health system, patients are left to their own devices. When a 6 year old girl was struck by a car just outside the cluster of hospital buildings this last week, the father carried the child into a Pediatric Emergency Room – a distance of only 50 yards – but was turned away. Just outside the door of the Holding Center the child’s life passed despite the efforts of the ambulance crew assisted by a team from Germany. Today, we diagnosed a mother with a fetal demise and Ebola. She will be transferred to a treatment facility where, due to the havoc wreaked by this treacherous virus on pregnant women, her survival is unlikely.
Today’s baby being held in the mothers arms represents the first infant born alive since I began work at the center almost two weeks ago. We have lost one mother to encephalitis, possibly due to rabies, and one due to an unknown infection that ended her life only one hour after she arrived. Another young mother died in the outpatient facility of post-partum hemorrhage after arriving in a taxi from a home birth. There have been three still-births. Celebrating the birth of the little girl has provided some balance to a time burdened with tragedy but buoyed by the ever hopeful spirits of an auspicious people.