To Prevent The Next Plague, Listen To Boie Jalloh
This is a landmark week in West Africa. For the first time since the Ebola outbreak, there were no new cases reported in Guinea, Liberia and Sierra Leone.
There are many unsung heroes who deserve credit for this milestone. One of them is Dr. Boie Jalloh, age 30. Ten days after he showed up for his medical residency at 34th Military Hospital in Freetown, Sierra Leone, he received a letter requesting his presence at the hospital's newly constructed Ebola unit.
That was in August 2014. The virus had reached the capital city, and the unit was immediately overrun with patients. Jalloh learned fast because he had to. Months later, as international organizations arrived in West Africa to join the battle against Ebola, Jalloh served as a wealth of information on how to treat the disease and design Ebola units to suit the local context.
If you meet him, you'll understand why. He solves problems by weighing evidence, as a doctor would; he recites exact details in a manner that reflects the military training that was part of his education; and he displays compassion fostered by his faith. I met Jalloh in Sierra Leone this past August; we continued our conversations once I returned to the United States in a series of phone calls, repeatedly cut off by lapses in the connection, and drowned out by the sound of downpours. What follows is an edited version of our talks.
How did you and your family respond when you were ordered to work in the Ebola unit?
My family said I should leave the country. Other people told me that if I agree to work there, I must want to kill myself. But I tried to ignore them. I thought, I must do this because I went to medical school with a grant from the government of Sierra Leone, and it would be betrayal if now I refuse to give back.
I was not afraid, either. I'm an imam like my father, and in Islam, it is such a holy thing to be a physician. The holy Quran says that if you save one life, it is as if you save the whole of humanity. I was not scared of dying because in the Quran, dying is just the beginning of another life. A child cries when it is born because it thinks the mother's womb is perfect, and it does not know what lies ahead.
If you're not afraid to die, why did you bother to wear protective gear in the Ebola wards?
My mother. She said, I do not want a dead hero.
Were you worried that you didn't have enough experience as a doctor to help patients?
When I graduated medical school in 2013, and started my first internship, I was terrified that I'd make mistakes because I trained in Africa and not in Europe or the United States. But I became confident after I read the book Better: A Surgeon's Notes on Performance by Dr. Atul Gawande. In it, Gawande wrote about how as a young doctor, he was terrified to practice. I related to that feeling so much, and once I knew that it was normal, it improved my confidence in confronting challenges.
What was the Ebola ward like during the first few months of the outbreak?
In August and September, it would take more than four days to get a diagnosis back from the laboratory. And even if it came back positive, there weren't enough beds in the Ebola treatment centers for patients. Ebola holding centers [where patients with high fevers and other Ebola symptoms stay until their diagnosis] are much harder to manage because you really want to be sure that the virus can't spread from one bed holding a patient who might have Ebola to the bed of someone who doesn't.
By September we were getting close to 60 patients a day in the center, and it was raining heavily. The center was made of old tents, so it leaked, and our patients were soaked. I really wanted to replace the tents, but we didn't have the supplies. We sometimes didn't have PPE [protective gear] for the health care workers and drugs for our patients. And we desperately needed ambulances. Another frustration was the lack of hazard pay for health care workers, who kept going on strike to protest the work conditions and the lack of pay.
What lessons did you learn from those early days?
Because it would take so long to get a diagnosis, we started treating suspected Ebola patients with intravenous fluids before their results came back — and we noticed that they were getting better even before they got a positive diagnosis and could be transferred to a treatment center. This was at odds with the policy of MSF [Doctors without Borders]. They only gave IV fluids once a confirmed Ebola patient was in a very late stage of the disease. Myself and the other doctors working at 34th Military Hospital held a meeting amongst ourselves and decided to treat suspected patients as soon as they checked in. That became the national policy practiced at all government-led Ebola centers.
Were you satisfied with how Westerners responded to the outbreak in West Africa?
At the beginning, the international response was slow and sluggish. We thought Europeans and Americans will never help us because they don't think Ebola can reach their shores. But once it did, the response picked up. In October and November , the British Royal Army and the British government promised Sierra Leone 700 beds to hold patients because our Ebola wards were overflowing. At that time, I was representing RSLAF's [Sierra Leone's armed forces] medical team, and the British asked me for advice on how to build Ebola centers properly. They had previously funded an Ebola center in Kerry Town [in the hills outside of Freetown] that had become really expensive, was inflexible, and very slow to open. They didn't want to repeat that experience.
Did Western officials listen to you and your colleagues?
Mainly yes. There were a few incidents in which we as locals felt offended by some of the attitudes of our international partners, but by and large, the collaboration was good. Our colleagues from the U.K. military were clear about saying this was our fight, and that they were here to help us. Also, I learned a lot from a few doctors with the World Health Organization about infection prevention control.
In August 2015, a lot of people in Freetown were alarmed by the news of a patient escaping from one of the Ebola wards affiliated with 34th Military Hospital. Were you shocked?
I knew escape would be a problem. In December 2014, I had talked with DFID [the U.K. government aid agency] about this. They had agreed to sponsor a new Ebola unit staffed by us at 34th Military Hospital. While they were planning it, I told them that we must surround the unit with a mesh fence that cannot be breached but that you can see through. For example, the type of fence at a baseball diamond. Someone on the team of British engineers and financiers told me, that sounds nice but it is not necessary.
Instead, they made a fence out of cheaper tarpaulin [a plastic tarp]. We knew stray dogs break through tarpaulin, and we feared that patients might breach it as well since they're often frightened in the unit and want to return home. The fact that you can't see through tarpaulin is a major problem because it makes the unit feel like a prison to patients and their relatives on the outside, who can't peek in to see their loved one. We were told to schedule visiting hours when patients could walk to an area where their family members could see them, but that didn't make sense because Ebola is very deadly. It's no good if the visiting hour is at 17:00 and the patient dies at 16:00 before their family has a chance to see them one last time.
Our first Ebola unit at 34th Military Hospital had a fence around it that you could see through, and that made a huge difference because it meant that families could see their relatives and see that they were cared for. That encouraged people to come to the hospital when they or a family member had a fever.
This past August , the engineers finally constructed a mesh fence around the unit after a patient escaped from one of the wards by breaking through the tarpaulin barricade. I know this was not the first patient to do so.
How have your activities changed as Ebola diminishes?
In April I began training health workers across the country in IPC [infection prevention control], which is intended to prevent the spread of Ebola and other communicable diseases. IPC has two components: There's the software, which includes making sure that people are trained in IPC and that clinics have standard operating procedures to halt new infections. The hardware is ensuring that if you're telling health providers to wash their hands, they have water; and if you tell them to incinerate their waste, they have an incinerator. In Sierra Leone, the hardware component is a big problem because it's expensive to build infrastructure. Most hospitals and clinics don't have running water, and some don't have electricity.
But in the meantime, we're doing what we can. I'm trying to incorporate lessons I've learned from Atul Gawande. In Better, Gawande writes about how doctors and nurses forget to wash their hands between patients whether they're in America or in India, meaning, it's not a matter of people being too poor or too uneducated to understand rules. Instead, Gawande says that people generally resist anything new until that new thing is more comfortable than the alternative.
So here in Sierra Leone, health workers have to walk a distance to wash their hands. That's a problem because if they have to do a round in a ward with 20 patients, and then move on to another ward, it's difficult to walk across the hospital grounds to wash their hands between every patient. No matter how many times they're told to wash their hands between patients, I know complacency will set in if the chore is inconvenient. They'll think to themselves, this patient looks clean, so I don't need to wash my hands. To solve this problem, I wish we could make the task easier by putting a hand-washing station between every two beds in a ward. This station would consist of a bucket of soapy water, a small table for the bucket to sit on and a bucket that is a receptacle. If local furniture makers build the table, the whole station would cost a total of $20. But for now that is too expensive, so we are just putting one station in every ward.
Is the health system able to withstand the added burden of survivors suffering post-Ebola syndromes?
It's been difficult, especially since we don't know the impact of the virus in the long run. I hope we can learn a lot about the disease by helping them, and also monitoring our thousands of survivors for five or 10 years.
However, although we need to focus on survivors to some extent, we recognize that many of their problems, such as malaria, are not caused by the Ebola virus. In that respect, a better way to tackle their problems would be to improve the health system in general.
To me, first and foremost, I wish the government and our international partners would invest in medical education. We really need more doctors and nurses here — we needed them before Ebola. You can supply all the drugs you want, but people won't be able to get those drugs if there is only one health care provider for 10,000 people. [Note: According to the World Bank, the number is 1.8 — compared to 100 in the U.S.]
We also need investment in postgraduate education for nurses and doctors. Right now, doctors need to leave the country to get any specialist training. That's why we have no specialists outside of Freetown. If you have an eye problem in Kenema, in the east, you have to travel across the country to see Dr. Vandi, the only ophthalmologist in the public system in all of Sierra Leone. Commander Sahr, the head of 34th Military Hospital, has been encouraging me to specialize in infectious disease, but I don't know how I can do it. I just have to be patient and hope I can find a scholarship.
In the U.S., older generations sometimes judge millennials as entitled and needy young adults who are addicted to social media. What do elders say about your generation in Sierra Leone?
It may be a little different here because I didn't get onto the Internet until college. But still, older people often claim that they were better educated and had more respect for their elders than people of my generation. But when I have a private discussion with older people who say this, I tell them that I'm not sure that their better education benefited them. Since our independence from Britain , our elders have failed this country. Everything is destroyed here. I hope that my own generation will turn things around.
Freelance writer Amy Maxmen covered the Ebola outbreak for National Geographic, The Economist and other outlets. Most recently, she traveled to Sierra Leone for "The Next Outbreak," a digital collaboration of The GroundTruth Project and NOVA Next.
Tweet to Amy at @amymaxmen