My Battle with Ebola

The sudden wailing of an ambulance awoke my senses like a slap in the face. It was the first of many sirens I heard the day I arrived in Monrovia, Liberia, the epicenter of the Ebola crisis in West Africa. The World Health Organization (WHO) had asked me to help develop guidelines for dealing with Ebola-infected waste, so there I was.

Street market in downtown Monrovia (Photo by Dr. Jorge Emmanuel)

For more than eight centuries, diverse ethnic groups were drawn to this fertile land where Melegueta pepper and other spices grew abundantly; some of the same spices today scald the mouths of visitors sampling the local cuisine.

Fish in spicy cassava leaves and rice (Photo by Jorge Emmanuel)

In the 1800s, free African Americans from the United States left for the African continent to colonize the indigenous peoples. The “Americo-Liberian” colonialists established the Republic of Liberia modeled after the U.S. with political power limited mainly to themselves and their descendants, excluding the native inhabitants from citizenship until 1904.

A US-backed military coup in 1980 shattered decades of autocratic rule, triggering the start of a bloody civil war. My Liberian driver John F. told me how he and his children hid under the floorboards of an abandoned house for three days without food to escape the fighting. By the time the civil war ended in 2003, 95 percent of the country’s healthcare facilities were destroyed.

The country was on its way to recovery in March 2014 when innocent civilians started dying in the hands of a mysterious assassin –- an invisible but deadly killer named after the river in Zaire where it first appeared: Ebola.

Ebola virus as seen with a transmission electron microscope (Source: whatisebolavirusinfection.com)

Ebola belongs to a family of filoviruses (so named because of their filament shape) of which there are five known species. One of the species—Reston ebolavirus—has a Philippine connection.

It was first discovered in crab-eating macaque monkeys imported by a lab in Reston, Virginia, from the Philippines in 1989. Reston ebolavirus was the first Ebola virus found outside Africa and found only in one macaque species in the Philippines, until it was later also found in domestic pigs. Although it kills infected monkeys and pigs, the Reston virus seems to be harmless to humans.

The same cannot be said of the Zaire ebolavirus, the deadliest of the five and the strain responsible for the current epidemic. In some places in Africa, Zaire ebolavirus has been fatal to up to 90 percent of infected men, women and children, virtually wiping out entire communities.

At first an infected patient comes down with a fever, headaches, nausea, diarrhea and vomiting—symptoms no different from malaria. Ebola then attacks the liver, kidneys and other organs, destroying collagen and causing blood clots throughout the body. Towards the end, many patients bleed from the eyes, nose, mouth and gaps in the skin. Death comes a week or two after the onset of symptoms and is caused by loss of blood, shock, and multi-organ failures. As of this writing, there is no known cure.

Ebola mural on the wall of the Liberian Environmental Protection Agency (Photo by Dr. Jorge Emmanuel)

Many healthcare workers did not know what they were dealing with when the Ebola outbreak started. Soon many doctors, nurses, nurses’ aides and ambulance drivers fell sick with the mysterious illness and died. As of December 21, some 666 healthcare workers were known to be infected in the three countries and 366 have died. 

Rumors spread, people avoided going to hospitals and some refused to believe there was an epidemic. Families in dense urban communities hid ailing relatives in an attempt to avert the stigma, thereby infecting whole households. All schools and universities were shut down on August 1. When an entire urban poor community of 75,000 was quarantined, desperate residents attacked the Ebola center, stealing equipment and releasing the patients.

Ebola posters found all over Monrovia (left) and Freetown (right) (Photo by Dr. Jorge Emmanuel)

Today, just about every other street in Monrovia has a street sign, poster, billboard, or mural about Ebola, its symptoms, the number to call, what to do and what not to do (e.g., do not touch the deceased). The message has gone out: Ebola is real and can be stopped; Ebola is not a death sentence; early detection and treatment increase the chances of survival.

Dr. Jorge Emmanuel and Johann Hoffman of Medi-Clave with germ-killing technology built by Africans for Africa (Photo courtesy of Dr. Jorge Emmanuel)

Like other viruses, Ebola cannot replicate outside the living bodies of humans or animals. If Ebola viruses in waste and other inanimate objects are destroyed, one important link in the chain of infection is broken. Ebola is actually a fragile virus. Exposure to the sun degrades the virus. Half of the Ebola viruses in the droplets from a sick person’s cough die within 15 minutes. Hot water at 60ºC kills 99.999 percent of Ebola viruses in 22 minutes. 

Last September, as chief technical advisor to a UN agency on medical waste, I completed work with a South African company on an autoclave to sterilize infectious waste without generating smoke and toxic fumes as incinerators do. The technology uses pressurized steam at 134ºC. My tests indicated that the technology would destroy Ebola in a matter of seconds.

In October, I was requested by the World Health Organization (WHO) to help develop guidelines for dealing with Ebola-infected waste. I had worked for years with my friend and WHO’s medical waste expert, Yves Chartier. One of the last things we did together before he died in a tragic accident in 2012 was to update the WHO guidelines on medical waste.

His position was never filled due to budget cuts, so WHO had to rely on outside experts.

As reports came in that some Ebola waste was being dumped untreated into open pits, it became clear that a medical waste expert was needed in the Ebola-affected countries. Around October 27, the United Nations Development Program asked me to support the West African countries. 

Jorge Emmanuel and Dr. Babacar Ndoye examining a UK incinerator at an Ebola Treatment Unit  under construction (Photo courtesy of Dr. Jorge Emmanuel)

My role was to assess existing Ebola waste management practices, train hospital staff including administrators and waste workers on safe management of Ebola-infected waste, and provide clean technologies for destroying the Ebola waste to selected hospitals and Ebola Treatment Units.

Dr. Babacar Ndoye, a virologist and medical professor from Senegal, joined me. He had just retired as head of the Senegalese Ministry of Health’s infection control program. He was one of the first doctors to volunteer in Guinea at the start of the Ebola outbreak. We had worked together since 2004 on introducing the first waste treatment autoclaves in Senegal and developed a national training program on medical waste management and infection control. As we pointed out to everyone who would listen, Ebola waste management is not just a technology, but also a whole system of management that needs to be put in place.

Upon arriving at Roberts Airport in Liberia, I was immediately reminded that this was an Ebola-affected country. Even before entering the airport building, all disembarking passengers had to line up and wash their hands with 0.05 percent hypochlorite (bleach) solution.

Washing stations with 0.05% bleach solution (left and center). Basin of bleach for washing shoes (right) (Photos by Dr. Jorge Emmanuel)

This procedure was required of everyone before entering any government building, grocery store, restaurant, hotel, coffee shop, or other public establishment. Some health facilities even had basins of bleach for decontaminating shoes. African colleagues joked that their hands would soon be bleached white. I pointed out that alcohol hand rubs were safer and more effective, but hand sanitizers were more expensive. Instead of handshakes, I learned to do the elbow bump.

Island Clinic in Bushrod Island is a former private clinic transformed into an Ebola Treatment Unit (Photo by Dr. Jorge Emmanuel)

In August 2014, Liberia was in desperate need of hospital beds. As bodies piled up along Monrovia’s streets, more than 100 laborers worked 24/7 for three weeks to transform Island Clinic into a 120-bed Ebola Treatment Unit. Within 24 hours of opening, Island Clinic was already filled beyond capacity.

Some patients stumbled in, ambulances brought others were. I heard stories of fathers bringing their children, too weak to walk, in wheelbarrows. UN colleagues pointed out streets where they had seen many bodies of people who collapsed and did not make it to the clinics. While touring Island Clinic I spoke to two sweet young girls, about eight and ten years old, who kept waving at me from their window in the recovery ward. “How do you feel?” I asked from outside their window. “Much, much better,” they replied together. It was a good sign and brought hope that these little girls would survive. 

Many of the incinerators brought into the countries on an emergency basis did not meet international standards. The heavy black smoke, along with carbon monoxide, hydrochloric acid, cancer-causing compounds called polychlorinated dioxins/furans and other toxic by-products from the new incinerator blew directly into the homes in highly populated communities.

Toxic by-products from incinerators affected homes in nearby communities (Photo by Dr. Jorge Emmanuel)

Because the full body suit is highly flammable, operators run the risk of going up in flames. Sébastien, the brave International Red Cross worker who volunteered to run the incinerator, removed his suit in favor of heat-resistant overalls. He used a long wooden pole to push the yellow infectious waste bag into the incinerator while keeping away from the intense heat. He then had to dump water on the smoldering stick and wooden platform. Burn barrels are used where no other options are available.

Sebastien, the International Red Cross worker, uses heat resistant overalls when running the incinerator (Photo by Dr. Jorge Emmanuel)

Dr. Bernice Dahn is Deputy Health Minister and Chief Medical Officer of Liberia. After her government announced that people who had been exposed to Ebola should isolate themselves for 21 days to prevent the spread of the disease, her own assistant Napoleon Brathwaite III contracted Ebola and died. A widower, Mr. Brathwaite left behind eight children who are now without parents. Dr. Dahn went into self-imposed quarantine, separating herself from her husband and children, as an example for the country. After 21 days, the maximum incubation period for Ebola, she emerged symptom-free. Later, I sat in her secretary’s office to do some work. When I was finished, I bid farewell and offered my condolences on the passing of Mr. Brathwaite. It was only then that the secretary mentioned that I had been sitting on his chair the whole time.

The author and Dr. Bernice Dahn, discussing the wording of the agreement between UNDP and the government (Photo courtesy of Dr. Jorge Emmanuel)

Ebola waste piled up in a temporary storage building, with boxes spilling over with contaminated syringes. One dumpsite overflowed with bloody bandages and other infectious items. 

I met four Filipinos. After a busy morning last November, my colleagues and I had lunch at a Lebanese restaurant in Monrovia, Liberia. Two people behind the counter preparing the chicken shawarma kept looking at me. I came closer and saw that they were Filipinos, Roman Tuzon and Gerald Aguilar. They had been in Liberia for four years. There were hundreds of Filipinos in the country, they said, and they were all scared.

I also met Herlynn Alfonso, a human resources specialist with the UN in New York, who volunteered to work in Liberia. She stayed at the modest hotel that I was in. It turns out her cousins run the Filipino store near my office in California. In Freetown, I met a Filipino nurse at the UN clinic, Ronel Maban. Both he and his wife, also a nurse, volunteered to work in Sierra Leone.

Roman Tuzon (left) and Gerald Aguilar in Monrovia. Ronel Maban of Freetown (Photos by Dr. Jorge Emmanuel)

We installed the first medical waste treatment autoclave at the Ebola Treatment Unit of a military hospital in Sierra Leone. The command hierarchy in a military hospital made work easier. For example, since many businesses had collapsed or shut down due to the crisis, it was difficult to find a forklift to move equipment. But in a military hospital, all I had to do was find the highest ranking officer around and in a matter of minutes we had enough human power to move things. It also helped that my colleague, Babacar, is a retired colonel in the Senegalese Army.

Installing the medical waste treatment autoclave by hand. Since most of the businesses shutdown during the crisis, it was difficult to find a forklift. (Photo courtesy of Dr. Jorge Emmanuel)

Putting on personal protective equipment (PPE) is a long laborious procedure that requires being paired with a trained health worker who assists in the process. PPE includes scrubs, boots, full body suits, double or triple gloves, face masks, goggles or face shields, hood, and a liquid-resistant apron.

We explained to the staff that the face shield should go inside the hood, but it took us another day working with them to figure out how to fit the shield inside the hood. Eye goggles are better but they often fog up, making it difficult to see. The hood, face mask and face shield often made it difficult for me to hear and be heard. Some Ebola Treatment Units write your name on your sleeve, otherwise you do not know who you’re talking too.

Within 10 minutes of donning a body suit in the hot weather, I found myself thoroughly drenched in sweat from head to toe. Even local health workers used to the heat came dripping out of their suits. However, I was so focused on work that I managed to ignore any physical discomfort as well as my slight claustrophobia. In fact, the only thing that bothered me was the oversized boots, which made it hard for me to walk fast.

Removing Ebola-contaminated personal protective equipment is a slow and dangerous process, beginning with being sprayed from top to the bottom of the boots in bleach. After removing the apron, the next step is to stand in a tub of hypochlorite solution while soaking the gloved hands in a disinfecting basin for three minutes. Then comes a complicated process of slowly peeling off each layer in a prescribed manner. Despite having taught this process many times, I was grateful to my paired observer standing outside the decontamination tent and shouting out instructions.

Personal Protective Equipment (Photo courtesy of Dr. Jorge Emmanuel)

I visited the Ebola Treatment Unit in Conakry, Guinea, run by Médecins Sans Frontières (MSF) or Doctors Without Borders, one of the heroes of the Ebola saga. MSF sounded the clarion call for emergency response as early as March 2014 but the world ignored them. Even as international NGOs withdrew their staff in fear, MSF increased its personnel and partnered with local health workers to fight the spread of the virus with almost no outside help. The epidemic would have been much worse and many more would have died if not for the intrepid souls of MSF, an organization I am proud to support.

In Conakry, I saw a gigantic Kapok tree rising above white tents, red mesh, and blue tarps, standing majestically over MSF’s Ebola center like a shepherd watching over a flock. As we entered, Babacar and I paused to watch two teary-eyed MSF workers caressing a tiny girl with gaunt legs like pool cues sticking out of threadbare clothes. She sat on a plastic seat and tapped her bare feet at the edge of a chair on which lay a tattered stuffed animal in a plastic bag, perhaps her sole possession. She was being discharged, an elfin child who defied Ebola and survived. Seeing her made my heart soar.

A Christian pastor said some prayers in a low doleful tone and led the congregation in a hymn. The first deceased to be brought out was a 33-year old man, a fact I would not have known if I had not glanced at his tomb marker, which one family member was carrying. As soon as the white body bag came into view, there rose a collective wail that broke my heart.

A congregation remembering those who passed away (Photo by Dr. Jorge Emmanuel)

The burial team placed the shrouded body in the casket. No one was allowed to go near. The mother and siblings were distraught. She gave a mournful cry and collapsed to the ground. Everyone cried. Imagine the sorrow of a mother who cannot touch or even see her dead son for the last time, in a country where kissing and touching the body (known as the final “love touch”) are an integral part of the grieving.

The procedure was repeated four more times: Burial teams brought out a white body bag and laid it on the ground, the name of the deceased was quietly announced, friends and family members of the deceased came forward but were told to keep their distance, mourners were given a few minutes to grieve, and then the body bag was placed at the back of the Red Cross/Red Crescent pickup truck.

After all five bodies were on the rear cargo bed of the pickup truck, the burial team sprayed hypochlorite solution in all spots where the body bags had touched the gravel. The pickup truck led a procession followed first by another Red Cross/Red Crescent vehicle with the burial team in their yellow full body suits. They alone could touch the body bags or casket.

The Red Cross/Red Crescent vehicle which took care of victims who passed away from Ebola (Photo by Dr. Jorge Emmanuel)

One Sunday, Babacar and I decided to explore the small urban poor community next to our hotel. There must have been 30 families crammed along the narrow pathway that led to the ocean. Neighborhood children were eager to show Babacar and me the crabs they had caught.

“I am your friend,” Simon, one of the children, said as we parted. It was a simple reminder of why I served in the Ebola-ravaged countries of West Africa and why I will return in February 2015.

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Dr. Jorge Emmanuel

Dr. Jorge Emmanuel is Chief Technical Advisor on healthcare waste for the United Nations Development Program (UNDP) and has been involved in environmental and health projects in about 40 countries. He is a co-founder and first board chair of the non-profit Filipino American Coalition for Environmental Solidarity in the United States. Recently, he served as a member of a World Health Organization’s advisory group developing the guidance for the management of Ebola-contaminated waste, and spent time in Liberia, Guinea and Sierra Leone last November and December to support the fight against Ebola on behalf of UNDP.