On the ground: a perspective of the Ebola outbreak in Sierra Leone by a US Nurse

Author: Janice Bonsu | This is an interview that was done for the project20 Institute

Just a couple years ago, the world was reckoned with one of the most fearsome infectious diseases. From 2013 to 2016, the most widespread outbreak of Ebola ripped through a number of West African countries including Guinea, Liberia, and Sierra Leone. There are many lessons to be learned from the identification and response to this epidemic. Ebola is hemorrhagic fever, that though rare, is incredibly contagious. Part of the difficulty in managing this disease is that researchers don’t know with certainty what is the natural host of the virus, though theories have hypothesized it is most likely bats. People contract Ebola through direct contact with blood or bodily fluids (even from someone who has died from Ebola), infected objects like needles, and fruit bats or primates. On March 29, 2016, more than 3 years after the outbreak was identified, the World Health Organization terminated the Public Health Emergency of International Concern for the disease. In total, the Ebola outbreak is estimated to have taken 11,300 lives – primarily that of healthcare workers and first responders. This number is, at best, a hypothesis, because of the delay in recognizing the outbreak that began in December 2013. The stuttering of the international community’s response and the rate at which the disease overwhelmed fledgling health care systems of these countries contributed to the severity of this outbreak.

Elizabeth, who served as the Director of Monitoring and Evaluation for Partners in Health in Sierra Leone

While many of us watched in horror at the outbreak, a few brave and generous health care professionals packed their bags to set out to aid in the emergency response at the height of the disease. We were honored to sit down and interview one of them: Amy Elizabeth Barrera, a public health professional who focused her studies on infectious diseases. During the Ebola outbreak, Elizabeth served as the Director of Monitoring and Evaluation for Partners in Health in Sierra Leone. There, she was responsible for collecting clinical data on patient outcomes. But that's just the beginning.

JB: Hi Elizabeth. Tell us a little bit about yourself.

I grew up throughout the southern states of the US, predominantly in South Carolina and Georgia. I’m of Mexican American heritage, my parents immigrated to the US before I was born. As an undergraduate, I went to Emory University and studied medical anthropology. Realizing I had an interest in public health and seeing the discriminations of the Latino population in the south, I set out to help. I felt that public health had the science and rigor that catered to my medical side and still dealt with the systemic issues that affected health outcomes and needed to be addressed. However, before going for my Master of Public Health, I decided to take the advice from a professor who insisted that I go somewhere and get out of my comfort zone. At that point, I had never traveled out of Latin America.

My professor helped pick a project for me and I set off to South Africa. It was a challenging project. I was in a community that did not speak English, but Xhosa. I eventually learned Xhosa by going to an intensive three-month language course at the University of Cape Town in South Africa (UCT). I then went to work in a very rural area as a research assistant and data collector. I conducted interviews and did transcriptions (with a linguist at UCT) to understand the challenges of designing and evaluating interventions to address the STI incidence in this village, which was on a major trucker route. After that year, I returned to Emory University and completed my Master of Public Health, concentrating in global health.

JB: How did you find your first job after graduating?

After graduation, like many other millennials, I had difficulty finding a job. I was very green and new to public health. They told me what they tell many other millennials – that I wasn’t experienced enough. It was rejection after rejection and I finally contacted someone in Partners in Health and said: “hey, I know I’m brand new in MPH and have very limited experience, but this is my life’s passion and I’m willing to come and work for you. I can’t work for free because of my loans, but I am willing to work for the bare minimum either in the headquarters in Boston or abroad.” I mean, I guess it worked! December 2009, I got the job on a Wednesday and was on a plane that Saturday to Rwanda.

JB: So, from Atlanta to Partners in Health in Rwanda, I know a lot of people our age who have friction doing some of these international experiences because of familial concerns. How did you manage that?

At the time, Partners in Health was building up their Rwanda site, trying to understand the clusters of HIV and the communications going on in the country about its management. I’ll be honest, no one in my family had ever traveled to Africa. I was the first when I went to South Africa. Most Americans are often times not always in the know about global affairs and global issues. My mom was worried about safety, not necessarily about my happiness. She knew that’s where I would be happiest. So, we established a communication protocol and said every other day at this set time, you and I will talk. Little did we know, Rwanda is actually one of the safest countries I’d ever live in – including the United States. It is about the size of Maryland, with 10 million people, lots of social programs established, everyone gives birth in health clinics, it is exceedingly safe. I walked around at night and never experienced any violence at all in Rwanda.

I stayed there for a couple of years and fell in love with someone I met while there. He was coming back to work in the Boston headquarters and that’s what brought me back to the US. We ended up working in Boston and I worked on a few tuberculosis projects, traveling a lot with Partners in Health. It was a mind-blowing experience, we went to Ministries of Health in Bangladesh, Vietnam, Zambia, many other countries, seeing how we could work with them to address multiple-drug resistant tuberculosis in their countries. I learned there that cultural ideology, the history of the place, resources available to the countries, all of this obviously affect how they manage disease, so it varied country by country. There are some drugs that are still utilized in other countries that we know aren’t that effective, but they are inexpensive and available through the World Health Organization, so it’s used globally.

Everyone thinks things like HIV is HIV is HIV, and though there are certain principles of disease management that are universal, there is a lot of noise on the outside that are not medically related, yet impact how the patient will respond in treatment. I was doing that work when Dr. Paul Farmer came to my husband and said that Partners in health was thinking about helping the Ebola initiative in West Africa.

JB: Tell me about how you guys made the transition to the frontlines of the Ebola epidemic in Sierra Leone.

Dr. Farmer was following the epidemic closely and had concerns about the lack of human capital and resources on the ground. The board of PIH made the decision on a Thursday to get involved and he came to my husband that evening and asked if the two of us would be willing to go and work the initiative. We went home that night and talked it over and discussed what we would need as a family to do this. Things like advanced directives, living wills… we were educating ourselves quickly about the epidemic, but given that it was so unprecedented, we didn’t know what we were getting ourselves into. We took a couple of weeks to get into the details… we had a lot of discussions around our dog, actually! We were happy to go.

My husband went as the Sierra Leone country director. I was offered two roles because it was really hard to recruit for this initiative because a lot of people were not willing to go, with good reason. I was the Director of Monitoring and Evaluation. In that sense, I was in charge of the data collection systems that would be used in the Ebola treatment sites to make sure we were communicating with the other initiatives led by the UK military at the time. My other role, which took up most of my day, was infection control. It was reminiscent of my TB work. I was in charge of managing personal protective equipment (PPE) and ensuring that the infrastructure healthcare workers were working in was safe and met speculation. We got things in order and set off.

JB: That is incredibly fast! What were some thoughts going through your mind?

We were reading a lot, we read before the flight, all throughout the plane, we wanted to get an idea of what we were getting into. We arrived right before the peak of the epidemic. It was at its worst in Sierra Leone in July/August and we arrived in April/May. Though I did a ton of reading about Ebola before I went, maybe 5% of it was relevant and helped prepare me. There’s nothing you can read about culture or history of a disease that will prepare you to have all of those factors and books become your reality when you are on the front line.

JB: What were the first things you did when you arrived?

Well, PIH doesn’t go into countries and construct anything from scratch. When possible, we work with the Ministry of Health and take their lead about which facilities they would like our assistance with. The Ministry had identified the Ebola Treatment Units (ETUs) they wanted us in. It was an old abandoned primary school that they flipped overnight into an ETU. I don’t know how the government did it, it was a huge undertaking for them to do this mountain of work in that short amount of time. I couldn’t imagine having to do that in my own country that quickly, under that kind of pressure and under martial law conditions. Once we got there, they were getting us up to speed. We walked in. There are two zones in an ETU – the “safe zone (staff only area)”and the patient areas, whereby both confirmed and suspected Ebola patients were maintained. We were in the safe zone and I watched the operations of the Sierra Leonean healthcare workers. I watched them going in and out and moving around and I thought – this would be very challenging.

The only way to get this done well is to pull together. I won’t lie, also that first day, I felt like I might not get out of that situation. I felt at that moment, looking at everything around me, the unsafe conditions, the exhausted people (because at the time, the Sierra Leoneans were on month 6 of working the epidemic), they were exhausted, away from their families, and living in the treatment unit. I thought, I don’t know if I will come back from this. I said to myself though, that if the Sierra Leoneans could do this for months, then it proves the human spirit is capable.

JB: So, it wasn’t just Partners in Health working there, did you interact with other agencies?

Yes, in operationalizing an epidemic response, everyone has their unique part. The UK military was in charge of coordinating all of the partners and were responsible for quarantines and safety. Each NGO had different tasks. NGOs like PIH were operating ETUs, others were housing expatriates, others were providing food. Like, the World Food Programme started providing 3 meals a day for us workers. It elevated our spirits in a way that we all needed. Small things like that really bring back the humanity in us when you feel like the worse of the worse is attacking you. But everyone had their roles. One thing about this epidemic was that we all had to be a united front. There was no time for the typical global health politics that you hear about, when NGOs get territorial. There was so much work to do here so we met the mission together. In all my years working in global health, this is the only time people from different organizations learned to rely on each other. Multiple times, myself, in the midst of the chaos, I would go to other partners and say, “I’m embarrassed to ask for this, but I need more body bags because we’ve run out. And I’ll get you back when my shipment comes in.” It was somber, but we learned to collaborate.

JB: I know the epidemic was severe, can you give us a sense of what it was like?

Yes, at one point during the epidemic, Sierra Leone had 500 new cases a week and the ETU for Partners in Health were receiving 200 of those cases. We were in the center of the epidemic. Our unit was 108 beds and we had 167 people in there. We were just moving people wherever we could move them. It was a really tough time, we were working around the clock, everyone was running on fumes, but we had so much adrenaline pumping through our body. At one point, I didn’t sleep for 4 days and didn’t notice until someone reminded me that it was time to sleep. I went to lay down and couldn’t close my eyes, I was just staring at my mosquito net.

JB: Who were the other healthcare workers that were with you?

We were in a crutch, trying to recruit more Americans, more Europeans. Headquarters were trying to recruit people from all over the US. There were so few people who wanted to volunteer – and I understand. We just couldn’t get enough people in so those who were on the ground ended up doing a lot of jobs. You could be a nurse, but sometimes you had to go hunt down wooden spoons to mix chlorine batches for us to spray down our suits.

At one of our lowest moments, a huge van showed up that no one knew was coming. 30 Cuban doctors and nurses got off the van and I wanted to kiss all of them. We didn’t know they were coming. I don’t think I’ve ever been so happy to see a group of people in my life. In one day, they had their Cuban tent put up – we didn’t even have space for them – and overnight they extended it, put a Cuban flag up. My first question diplomatically was if there would be any difficulties collaborating because we are Americans. I didn’t want to deal with any political “BS” in the middle of this. So, I called my husband, the country director, and let him know I didn’t want to turn away good help and he said he would take care of the politics. They got to work right away. I mean, they didn’t speak a lot of English, the Sierra Leoneans didn’t speak Spanish, a few of us knew Spanish. It was a lot of the language of being human and pointing, but at the end of the day, we were all working together.

The only difficulties were among the stress of the Sierra Leonean staff and the policing that was going on around them. In order to minimize the potential of a Sierra Leonean watching a friend or family member die from Ebola, all Sierra Leonean healthcare workers were stationed across the country from their local community. they lived. They were displaced and throughout the epidemic, they would get news about a parent or child who died and they were forbidden to leave for the funeral. I mean it was stressful for us, but it was a tragedy for them. Those moments were very hard. We are all human and I would have wanted to go home and say goodbye if my son or mom died of Ebola, but they couldn’t. It fueled a lot of mental health issues that nobody was ready to tackle, but came with the epidemic.

JB: Can you speak about the community’s reaction during this time?

Well, Sierra Leone had just stopped fighting their civil war 4 years before this epidemic happened. It was a very hard time. There was mistrust and rumors in the community, and I totally get it. You just finished a civil war, the country is now at peace, and all of a sudden, a new disease that no one has heard about comes about. Must be an invention, right? I’ll say it out loud, we have a significant racial problem that impedes our relations and advancement as a society. There was mistrust of foreign healthcare workers. The offending racial group has rarely, if ever, admitted its faults, so a couple hundred years later, there is still angst against Westerners and the white people and the thought that now there is a new disease and look, it is those same White people who are on the ground to “help.” In my experience as a Mexican-American, all I know is that when white people show up, shit’s about to go down. So, we had a lot of problems in the community about people not trusting the ETU as a place to go for treatment. People were saying it is where you go to die. And at the epidemic’s peak, it was where people came to die, because it was so horrific.

People never saw family members again. A lot of anthropologists from the Centers for Disease Control and Prevention (CDC) came to get a sense of the stress and rumors in the community and also find the origin of the outbreak. They said it was from the traditional burial processes. But it’s hard to sell a burial process change to any culture. Saying I can’t bury the people I love, or see them, or even confirm they are dead because I’m not allowed to see their bodies. It was hard for the community to trust that. I know that in the beginning, Medicins sans Frontiers (Doctors without Borders) tried to show people their loved ones and give them that closure and have people put things in with them before the burial, but when the epidemic hit its peak, we didn’t have people to do that, so rumors kept building up.

The community reacted exactly how humans would react, especially with the historical racial undertones. It wasn’t their cultural beliefs or religious beliefs that impeded our emergency response, actually those beliefs helped strengthen the community during and after the epidemic. Sierra Leoneans have a resilience that is understated and needs more appreciation. I can’t ever disrespect them to say I can understand what they went through. They worked the epidemic for two years and every single one of them lost a family member and couldn’t go back for a funeral. One person who worked with us lost as many as 16 members of their family, and yet I saw him and worked with him every day. We have a lot to learn as a nation from countries like Sierra Leone.

JB: What are some of the precautions you had to take while living and working in Sierra Leone?

We were instructed to keep 3 feet apart from people at all times during the epidemic because it was the first disease in history transmitted through sweat. We didn’t know if that meant a little or a lot of sweat, so the rule was just no touching. That gets to be very hard when you want to show empathy and your first reaction is to hug someone when you hear they’ve lost someone. So, during this time, we had the “Ebola hello.” Instead of shaking hands, you would high five elbows in the air, never actually touching the elbows though.

JB: Recently, there has been a lot of talk referring to what is American isolationism. Less than 1% of the US GDP is used for global health, which some consider one of our most important diplomatic actions. What are your thoughts on this issue and what would you say if you had 30 minutes with the President to address this?

The way out of social inequities, hunger, poverty, you pick the topic… the way out is to start working better collaboratively. The active destruction we are doing to our planet is at a great cost. We are no longer fortress America. It became very real with 9/11, of course, but then again with Ebola. We were not prepared then, we are not prepared today. If Ebola walked through ah hospital here in Philadelphia, it would be mayhem. Just mayhem. Instead of learning from the global community, though, we want to shut our doors and turn up our noses. We have to get a different mindset about how we spend our money. We give 1% to global aid. That number needs to be increased, yes, but we also have to change the mechanism of which we provide that money.

We have to trust other countries that they know what’s good for their country and then we can learn from them instead of prescribing them methods. We have to stop giving money through US NGOs. We have to give our money directly to the governments and trust that they will spend the money best on their needs. It’s going to take a big leap of faith. People will shout corruption. Corruption is never an excuse to not do something. Of the small number of corrupt officials, the majority is not. The majority wants hot meals, education for their kids, healthcare for their families. We all want those things, irrespective of where we come from. We will make a dent in the global burden of disease when we allow the governments to measure it and put them in the front seat. Yes, we will push for accountability and set audits, but we need to change our mindset.

We also have to focus more of prevention as a country. Institutions here in the US pump “band aid” initiatives abroad. Until we realize that and think differently, we won’t make much progress.

JB: If you could give any piece of advice to young professionals who are interested in infectious disease management and engaging in global public health, what would it be?

I know it’s hard to get experience, but get experience anywhere you can. This also means locally. Not everybody is ready to go abroad or wants to go abroad. There are so many global health initiatives that you can get involved with locally. Refugees and immigrants are abundant in the US. You could even take time to go to the airport and see what the immigration process looks like for people coming in. I did it as a student and realized that people are treated so rudely, especially if they carry certain passports, especially if they are suspected of being sick. You could also go to homeless shelters, refugee clinics. A sad fact is that a lot of people who immigrate to the US end up homeless at some point. But more broadly, I would say it is really important for you to get out of your comfort zone and challenge you so that you are the recipient of learning.

Go to a situation where you don’t know anything. Go in, take it in, and listen. Listening is a skill that is necessary if you want to work in global health. I know that is hard for Americans, because we are often told we are in the position of power and authority, but you have to spend 70% of the time just listening to be successful in global work. Another piece of advice is to start thinking about what global health means to you. You don’t have to be in the wilderness of some remote country to do global health. Think about development, program planning, fundraising, there are a lot of ways to do global health. And if you do travel, I think it is wise to be mindful of your comparisons. There is a model of what people go through when they travel. The first step is that it’s amazing and great and different. Then people put it on Facebook. The next step is then comparing it with everything that they know. Don’t. Don’t compare anything from where you came from. Just be in the moment, even if you are tired and sick or grumpy. When you start comparing, you inevitably start setting one thing above another. And that really comes out when you are interacting with others.

On that same vein, you also don’t need to go full on native Don’t drink from the well if you aren’t supposed to drink from the well. The final piece of advice is that people always watch foreigners in a community, and the first thing they notice is how you treat their kids and their elderly. Americans generally don’t treat the elderly well, so we have to actively work against that notion. They are revered in other cultures, they have all the knowledge. Oh, one last piece of advice is to ask yourself would you still be interested in participating in your global experience if you could only take your diary and not a camera? Then go.

In all my years in the field, I have taken a handful of pictures. I want to be able to remember in here (points to head) and in here (points to heart). I know how I would feel if a bunch of foreigners saw me walking on the streets of Philadelphia and started taking pictures of me randomly without even asking. How would you feel? We really have to think critically about things like that. Other than that, you will be set. Global work is done to empower others.

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