Sierra Leone: A Place of Life, Death and Compassion

By Guest Contributor June 15, 2016 20:14

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In early 2015, Dr. Todd Stolp retired after 12 years as public health officer for Tuolumne County, California. Two weeks later, this husband and father of three boarded a plane for West Africa to treat Ebola patients. His assignment: help pregnant women in a country with the world’s highest maternal death rate, amid the largest global outbreak of a disease that kills half its victims. In this first-person account, he shares why he went, what he found and what he learned.

By Dr. Todd Stolp

I noticed her long before I boarded my plane at the Brussels Airport.

She was tall and graceful, her dress resplendent with angular African patterns and her head nearly shaved except for a tuft that stood up proudly in front. Despite my best efforts, I couldn’t avert my gaze.

Amazingly, I was destined to know her better. Her seat was next to mine on the flight taking us to Dakar, Senegal, Conakry, Guinea and finally to the West African nation of Sierra Leone, 3,000 miles to the south.

“Are you a doctor?” she asked, after we exchanged greetings. I felt a wave of self-consciousness as I realized that she had summed up clues from my appearance just as I had done in silently pondering hers. It occurred to me that her conclusions were likely more accurate than my own.

After 20 years as a family physician in Sonora, then 12 as Tuolumne County’s public health officer, I was flying to Sierra Leone to help fight Ebola.

PPE-Todd-Summer-2016-editedHired by Partners In Health, a nonprofit organization providing care in impoverished communities, I was joining colleagues from all over the U.S. in an international effort to contain the often-fatal disease’s outbreak in West Africa.

Our team of 12 had just completed training in Boston, and by dawn we’d be in Freetown, Sierra Leone’s crowded, ramshackle capital. There we’d begin more advanced training in treatment protocols developed since the world’s largest Ebola epidemic erupted 10 months earlier.

Because nothing before it had matched this outbreak’s size, there was little prior research. Also, developed countries had not seen Ebola as a threat to their own populations, and thus had not devoted their superior resources to the disease.

Now, amid the epidemic’s seemingly relentless spread and deaths by the thousands, all that had changed.

My elegant partner in Row 6 was acutely aware of the tragedy. Her Sierra Leone village was outside Kenema, where less than a year earlier, Ebola had taken the life of Dr. Sheik Humarr Khan. Despite appalling conditions, the legendary physician had remained at the Kenema Government Hospital’s Ebola ward during the outbreak’s peak in the spring of 2014.

The virus had also taken the lives of a number of my seatmate’s friends and family. She was now returning to her village from Germany, where she and her husband operated a plastic surgery clinic for Sierra Leoneans mutilated during the country’s civil war a decade earlier.

Our team of eight physicians and four nurses from throughout the U.S. would arrive in a much safer environment than the one facing those who had come even two months earlier. Tireless researchers and casualties like Dr. Khan had brought new insights into how to protect caregivers. But those protective measures would never be fully effective nor free from further refinement. Where mysteries remain, one relies on whatever it is that extends beyond the finite limits of science.

Options for patients remained extremely limited. Fluid replacement and treatment for other illnesses that might masquerade as Ebola were among our few alternatives. Our job was to isolate patients and treat them when we could, sending blood samples to a Danish lab for Ebola testing. Two negative tests over 72 hours would clear a patient.

One of our greatest challenges was convincing this faraway nation’s sick to submit themselves to the sterile, alien isolation units. Trust us to protect you, we would tell them – even though we’re taking you from your homes and families. Although survival was becoming more and more likely as time passed, wary patients knew many of their countrymen had passed away in similar isolation units.

Before parting, my friend on the plane taught me how to greet strangers in Sierra Leone. Say “kushay” (my spelling), she told me, and the ice would break.

For the next several hours I whispered “kushay” to myself, firmly storing it in my vocabulary for the months ahead.

That I applied for a position with Partners In Health, in retrospect, seems natural. The timing of the Ebola outbreak, my pending retirement as a county health officer, and seven years on a statewide communicable disease committee that I co-chaired helped pave the way.

Also, I knew that without stimulus my skills and training would surely begin to oxidize – just as the oxidation of my aging body had already begun. So the call to Africa seemed almost preordained.

After a talk with my wife, Martha, I found the Partners In Health organization on the Internet and applied. I think Martha knew that I would have found little comfort retiring to our own little patch of the planet while an event so relevant to my entire career was broiling on in Sierra Leone.

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Stolp (center) with U.S. colleagues in Sierra Leone

Our plane set down across the bay from Freetown at 10:30pm. After making our way through a flurry of hawkers selling everything from cell phone cards to services that could not clearly be defined, we piled into a bus, then boarded a ferry. During the tiny powerboat’s 30-minute trip, we nearly hit a dinghy carrying three people engaged in suspicious activities in the dark.

Arriving in Freetown, we were treated to a fried-fish dinner, the intact fish looking up from a bed of rice. Before wearily climbing four floors to our rooms, we washed our hands, took our temperatures and recorded them in a logbook – all of which were required several times a day. The transition to long-overdue sleep was not even a memory.

Our first full day in Freetown began with a chorus of roosters and dogs. Below us were somewhat new buildings like our own, but in the distance sprawled a ramshackle community of corrugated aluminum and aged plywood.

Colorful garments hanging from clotheslines were a bright counterpoint to the drab weather-beaten gray background, combining with it as if part of an abstract painting.

A perpetually smoldering heap of rubbish in the distance put out a pungent aroma, replete with hints of plastic scraps and preferably forgotten organic matter.  This would mingle with the haunting scent of chlorine until the day of our departure six weeks later.

After an improvised sequence of showers, breakfasts, organization, and ritual temperature-taking and hand-washing, we took off for the national football stadium. There, doctors from Uganda who had earlier cared for Ebola patients would begin our training.

That first trip through town was eye- and ear-opening. Honking horns replaced traffic lights. Pigs mingled with families in vignettes that flashed by as we passed streams of gray water steered by banks of trash.

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Sign warns of Ebola symptoms

Advertisements bearing odd slogans like “Pure Monosodium Glutamate” were plastered on hand-painted walls. A small sign identifying the offices of Hezbollah hung among others for Coca-Cola and cell phone systems.

A melodic cacophony of the Krio language rose from crowds that encircled our car. Bright smiles came from the surging horde, many of whom were magically balancing absurd burdens upon their heads.

Although English is the official language of Sierra Leone, virtually everyone speaks Krio – Creole in our country. The dialect is related to English just enough to tease one’s efforts to understand the words – efforts that were often futile for my 61-year-old ears.

The nonstop hubbub of Freetown is impossible to describe without the benefit of visual, auditory and olfactory aids. Sensory overload may be an understatement.

During the next three days of training, my wonderful young colleagues – judging by the teasing, I was the oldest of the group – would awake each morning, don jogging clothes and seemingly self-propelled running shoes and ask anyone interested to join them for a two- or three-mile run.

I have always dreaded jogging, preferring to plod along in leather shoes in wonder at what might be around the next bend on a hiking trail. But in the interest of team spirit, I joined my new friends. I also saw the morning runs as an opportunity to practice my cheery salutation, “Kushay!” to people lining the curbs as we swished by. The locals smiled and waved, and I felt I was doing my diplomatic duty.

I was assigned to the Princess Christian Maternity Hospital, the only state-operated obstetrical hospital in the country at the time, and home to a Partners In Health isolation unit for women.

Pregnant women are at a much higher risk of death from Ebola and carry a much higher viral load than other patients. A German and Cuban contingent operated a similar children’s unit next to ours.

Using World Health Organization Ebola criteria, we screened patients before they entered the holding area. Had they experienced, for example, unexplained bleeding, fever, confusion, miscarriage, a stillbirth or nausea and vomiting?

But these symptoms alone, many of which can occur during otherwise normal pregnancies, were hardly proof of infection. More important was a patient’s specific history.  Had her friends or family members been ill? Had she been to the funeral of someone who had died of Ebola? Had she had sex with anyone who might have been infected?

We expatriates relied heavily upon the interviewing skills of our Sierra Leonean partners and interpreters – nurses, medical students, lab technicians. We also did our best to read patients’ facial expressions and to catch the occasional familiar English word.

PrincessChristianMaternityHospital-summer-2016-editedThe interviews were often emotionally charged, as we asked patients personal questions about sexual activity and experiences that could be enormously stigmatizing if not kept strictly confidential.

One patient, for example, didn’t tell us that she had recently undergone an illegal abortion. Had we known this earlier, her course of treatment would have quickly become clear. But she so feared the consequences that she remained silent. Luckily, she survived after surgery.

The attending American PIH physician would ultimately decide whether to admit a patient to the Holding Center. But that decision was almost always in accord with the recommendations and efforts of the entire team. This close partnership between our team, staff and local doctors, termed the “Accompaniment Model,” is a cornerstone of PIH operations.

Word of a pending admission spurred a flurry of activity in our tarp-enveloped center. Roles were quickly assigned: Some would escort the patient from screening, and others would receive her at the Holding Center. Requests from the Red Zone – where those with suspected Ebola were housed, completely isolated from other patients and the

public – were addressed by team members outside the zone. They provided medications or equipment by reaching through a doorway to carefully drop them on a table or toss them to us without entering. A cleaning crew armed with chlorine solution followed the patient and mopped up every place she had been.

All of us involved in patient care were first required to don Personal Protective Equipment. Before even beginning the donning process it was important to address one’s toilet needs and to drink plenty of water to protect against dehydration in the suit’s steamy confines. Dressing in a body suit, bonnet, respirator, fog-prone face shield, two or three pairs of gloves, booties and boots was a meticulous process that took 10 to 15 minutes. Leaving the Red Zone involved a ritual 15- to 20-minute scrub and a slow and deliberate doffing of safety gear under observation by another staff member.

Just before entering the Red Zone, a colleague would write your name and entry time with a marker in several places on your suit, since it was impossible to tell team members apart once they were wrapped like burritos. There was, however, a certain beauty to the resulting anonymity of race, gender and nationality.

Each day would start with the night staff’s status report on each of the three to eight patients at the center. One unforgettable case involved a 22-year-old who had tragically delivered a stillborn first twin at home on the day before admission.

She had become more and more agitated over the ensuing day, and met admission criteria with fever, delirium and abdominal pain – certainly explainable by the fact she was still in labor with twin number two. Feverish, bleeding and barely conscious, with a discolored and unclamped umbilical cord still disappearing into her body and a second twin still occupying her womb, the patient’s prognosis was dismal.

Sierra Leone has the highest maternal mortality rate in the world. There, nearly 1,400 women die per 100,000 live births. The U.S. rate, by contrast, is 14 per 100,000, according to the World Health Organization.

Deaths before the Ebola epidemic were caused by treatable or preventable conditions like eclampsia (associated with high blood pressure, seizures and kidney disease), postpartum hemorrhage, infection of wounds incurred in the birthing process, and malaria. Injuries during delivery were further complicated by the scars of genital mutilation, imposed upon nearly half of Sierra Leone’s female population.

Deaths from such complications escalated during the outbreak, as definitive treatment was often delayed until Ebola was ruled out – a necessary step to protect the community and medical staff. The 22-year-old mother was no exception.

As we entered her room the next morning, we found mayhem. The patient was naked and unconscious on the floor. The bedframe was on its side and the mattress across the room. Fluids puddled on the gray concrete floor, IV tubing was scattered and equipment was strewn about the windowless room.

Although worrisomely still when left alone, the patient became dangerously combative whenever we attempted an examination. There was little to be done but speed the delivery of an almost certainly dead infant to save the mother’s life.

We gave her intramuscular injections and the second twin, a girl, was delivered about an hour later. And the newborn surprised us all with a feeble but very noticeable attempt at a breath. Emboldened by the signs of life, our team jumped into action. Taking advantage of new equipment and using techniques members had learned only a week earlier, we turned that faint attempt into regular breathing.

Elation came with success, and daylight seemed to stream directly through the concrete walls and into that dark room. That the infant was wrapped in a richly colored African cloth only added to the joy of the moment. Her mother regained consciousness two days later and slowly recovered after Ebola was ruled out. Her infant daughter, who tested negative for Ebola, also survived and returned to the family’s village.

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Stolp chats with a survivor

Looking back on the pleasures and privileges of working in medicine these past 35 years, it perplexes me that each turn in my career was made possible by the turn before it. It’s a bit like the days when I used to hitchhike back and forth to college in Illinois. I knew where I needed to end up, but my path was largely unknown and dependent upon the kind souls who decided to invite me into their lives for a certain number of miles.

What I’m left with, even though each step was its own small decision, is gratitude for the lessons I’ve learned on every inch of that trail. From my time in Sierra Leone, I learned that human resilience has no predictable limit. Another lesson, thinking of that intrepid twin infant, is that success is only possible when you look for it.

Also remaining with me is a sense of humble disbelief that my patients – even those courageous citizens of West Africa – have invited me and my colleagues to enter their lives in the hope that we might bring them a better outcome. My own sincere hope is that I have justified the confidence they placed in us.

One day, riding back to our compound, I noticed the lettering on a box of tissues on the dashboard: “Kooshe.”

I commented on the odd use of the word for greetings as a tissue brand. Our polite driver pointed out that the word did not mean “hello” in Krio, at least not as far as he knew.

Seems I had been greeting my Sierra Leonean hosts with a smile and a cheery “Kleenex!” during most of my stay in their country.

Copyright © 2016 Friends and Neighbors Magazine

By Guest Contributor June 15, 2016 20:14
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1 Comment

  1. Nancy September 26, 12:54

    Wow. What a man of compassion and courage Dr Stolp is. He has made Tuolumne County very proud. A real inspiration to us all !!

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