Les Roberts – “Day 10: Leaving Columbia to be at peace with Columbia”

Les Roberts – Freetown, Sierra Leone – October 14th, 2014

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Day 10: Leaving Columbia to be at peace with Columbia

I am constantly struggling with being an academic at a time when there is work to be done in the world. There have been maybe five occasions in my life (e.g. detected a measles outbreak that had killed 1,500 kids and saw my local partners stomp it out, showed that a vaccine was working fine in spite of all appearances to the contrary…) for which I am quite sure hundreds of deaths were averted because I was there at that moment. I have not had anything close to these experiences since coming to academia full-time eight years ago.

There is a lot that’s appealing and a lot that’s appalling about academia. Imagine two young people come to the University trying to make an Ebola vaccine as a next career chapter. One comes up with a cheap safe vaccine with 90% efficacy after 10 years using $100 M and with 100 publications about the Ebola vaccine. The other comes up with an equally effective, cheap and safe vaccine with only $1 M and 10 similar publications along the way. By virtually every other measure within society, the second efficient researcher would be called good and the first would be considered at least inefficient or maybe even a self-promoting parasitic slouch… But in academia, it is just the opposite! (There might be one or two other downsides).

But the appealing part is the students. It is the appealing part when they are in school but it is the really appealing part when they are launched into the field. I had dinner last night with Bronwyn Nichol (PFMH ’12). She is here with UNICEF working on social mobilization. It is frustrating and trying work as communications people are running the show and the health agenda often seems to have been overtaken. It was so great to see her and see how after just a couple years in Chad (with the Carter Center) and Jordan, she has become so well rounded in terms of understanding the alignment of management, programs and objectives. She is here via the Canadian Government and at the end of this gig, she will be able to have all her student loans paid off…Something on many of your minds, I suspect.

At dinner, we saw and spoke to one of my former Hopkins students who has been heading the CDC team in Kenema. The outbreak is largely under control up there now and this student, Muireann, has been one of the loudest voices articulating why this district has done so well. The night before, another former Hopkins student who works with the International Rescue Commitee (IRC) health unit was at Laura Miller’s house when I went there for dinner. (Thus, four former students and Susan Purdin in two nights!) Laura (PFMH ’11) has been here over three years and has faced some reluctance from her HQ to take on clinical roles. However, the IRC President, David Miliband, was out here last week and they now have embraced treatment (a figurative expression) wholeheartedly. In just the perfect process of partnering, IRC is going to pair its logistics and operational capacity with a local British group who has been working in the hospital here for a couple years and are going to start opening tent-based holding facilities next to health posts around the city. It is a different model than the one the UN is pushing for in rural areas but it makes complete sense for Freetown. That Laura has been here for years, knows everyone and is brilliant but modest makes her the perfect person to make this happen. I am sure that in the years ahead this Ebola chapter will be for her the satisfying experience that stopping those Congolese measles outbreaks was for me all those years ago.

Thus, ironically, taking a leave from Columbia to dash off and do something quite unrelated to what I teach and research has brought me more satisfaction and peace with my academic life than most anything else in the past eight years. The idea that the Program on Forced Migration and Health has sprinkled other Laura Millers out there – individuals who will hopefully never be quite so tested and who will have more subtle successes – is very comforting.

Les

Les Roberts – “Day 7: Brutal Triage”

Les Roberts – Freetown, Sierra Leone – October 11th, 2014

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Day 7: Brutal Triage

The prediction landscape is looking bad. The official numbers reported are laboratory confirmed cases. Typically, we think people need seven to ten-ish days to become symptomatic. Typically people have symptoms for seven days before they get into a health facility. A month ago, it was one day, now it typically takes four days from when a patient is sampled to when the patient is told the result of their test (and lots get lost and mislabeled…). Thus, the numbers that you hear about new cases today reflect the transmission dynamics from over two weeks ago… and we thought the doubling time of the outbreak was 30 days, it seems to be less than that here. We knew the ~350 confirmed cases last week were an undercount… we now think there are seven to 900 in reality. The need for hospital beds is climbing more than the ability to get them up and running. There might be 200ish Ebola treatment beds now countrywide. There are perhaps 600 more in “holding areas.” We have schemes to get 500 or 600 Ebola treatment beds up and running over the next eight weeks. As Foreign Medical Team Coordinator, helping to get these beds up and supported is one of my primary tasks. If there are really 3000 cases this month, and 6000 next month… with all going perfectly on the treatment bed establishment side, we will have 30% of the beds we need next month, slightly worse than the situation now.

The Ministry of Health and WHO are trying to fill the void with Ebola Community Care Units (ECU’s). Tents with eight beds…. maybe two tents, a wet tent (vomit and diarrhea) and a dry tent and a big buffer zone around with a couple latrines and a burning pit and a water supply. They will be staffed by low level health workers or community volunteers, ideally survivors of Ebola who will have immunity. The idea is that at the first sign of symptoms, the family brings the feverish loved one in. Everyone will be treated with an antimalarial and an antibiotic. If they can be tested for Ebola, they will be. If not, they get monitored and if they develop three of the key symptoms they get referred to a proper hospital bed… which will be in short supply… or otherwise they move to the wet tent. They will be given ORS… maybe food… maybe they die, maybe they do not. This is very close to no treatment. But the goal is to get them out of their houses to where they will be less likely to infect others. The supervision will be scant. The work for those in the ECU’s will be very risky. Even MSF has had several staff infected now and they are hyper-vigilant and resource rich. But the logic is, for every health worker infected or ECU malaria patient who becomes infected with ebola while waiting in such a unit, two or three infections that would have happened if the person died at home will not occur.

We aspire that we will have ~150 of these going in 60 days… which involves a million dollars per unit, major logistic planning and supply chains, site preparation by the community, and well drilling… this will be a massive effort. But 2000 beds in ECU’s, 700 treatment beds… might be half of what we need by December. Thus, barring a dynamic change in the outbreak growth, in November, in December, most cases will likely die at home.

Thus, the CDC has been pushing kits and training messages to promote “safe home care.” The kits would have ORS (a lot…like 20 sachets) and gloves and masks and chlorine and an ORS mixing bottle. The kits’ design is yet to be finalized by the MOH and the international community. The main part of the kit will be messages to the family. Keep the person in a room alone, and no one shares their bathroom. Only have one person deal with them… don’t touch them… wear gloves… wash with chlorine as you exit their room. Again, like the ECU’s this is not about treating the ill as much as it is about minimizing infections. The logic flows like this:

If you think about it a few steps removed from West Africa, this is freakin’ wild. We are primarily trying to facilitate people to die without infecting others. Very little of this logic beyond the ORS is about treatment. The last year PEPFAR was in full bloom, with all the administrative layers and consultants, it spent $10,000 per patient to have Africans on anti-retrovirals. The rights-based advocates were screaming about how it was only fair that Africans get what Westerners got. In July, there was an Onion headline “Experts: Ebola Vaccine At Least 50 White People Away.” http://www.theonion.com/articles/experts-ebola-vaccine-at-least-50-white-people-awa,36580/  It seemed kind of funny then… now that we are being so brutal in our public health triage it is much much less funny… maybe prophetic. We are about to assist thousands and thousands of people to die an excruciating death at home without even the most mild of pain relief. We are going to set up treatment facilities in hundreds of villages for one of the most deadly of diseases to be largely run by volunteers who will be lucky to get 3 days of training. Dozens, perhaps hundreds of them will die. And the most surreal aspect of this triage for me is that I completely think that this is the right thing to do given where we are and the limited ability to respond. As I think about you students reading this I struggle with the degree to which my endorsement of this multipronged approach is pragmatism or wisdom or loss of idealism.

Les

Les Roberts – “Man, this is one heavy gig!”

Les Roberts – Freetown, Sierra Leone – October 7th, 2014

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I had a great lunch yesterday with Laura Miller (PFMH ’11) and Susan Purdin (former Program on Forced Migration and Health faculty who taught the Reproductive Health course for years).

What was so bizarre is that I could not hug them or shake their hand….no one does!  No one!   Last night I saw the British special Ebola Representative leave a meeting with the CDC lead here in country…. and they did not shake hands!  Everyone is washing their hands 20 or 30 times a day.   There are hand washing stations as you enter every hotel and government building and restaurant.   I have had my temperature taken 5 times today and 8 times yesterday.   Every hotel and office and controlled public facility has infra-red thermometers to scan your forehead before you enter.  Everyone…. poor and rich alike are hyper aware of this disease risk.

In order to control this outbreak there needs to be:

• cases suspected….calling in….self-diagnosing
• transport to a facility
• triage or holding of suspected febrile cases (w/ testing, diagnosing, treatment)
• contact tracing (which can lead back to step one)
• and safe burials

 CDC is convinced safe burials are the highest priority.  WHO thinks treatment capacity is the greatest bottleneck / priority (because identification, triage, contact tracing all don’t work if you can’t refer cases and if the health system is not trusted).

I do not know who is right but I am sure both are needed…it is all freakin’ needed.   I have been made WHO’s Foreign Medical Team Coordinator which really means getting hospital beds up and running…with all the training and management and supply chains that goes with it.   Not what I expected to do…..but maybe the most important thing I can do.   Today we likely do not have ½ the beds in country that we need for the existing cases.  I expect that we can triple the treatment beds in the next two months while I am here….and all modeling, even best case scenarios suggest, we will be even further behind the patient bed demand than we are now.

Man, this is one heavy gig!

Les

Les says farewell

We are all very proud of Les Roberts, professor of the Program of Forced Migration and Health at Columbia, who left September 29th to work with the WHO in Sierra Leone on the Ebola response.  We’ll be posting his updates here, so please check back often!

Hand-washing station at the entrance of Connaught Hospital, Freetown.

Please see below for an excerpt of his farewell email to his students.

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Friends,

I am sure that you all felt a little heartache as MSF and West African officials have pleaded for more help from the West during this ebola outbreak.  Both CDC and then WHO reached out to me requesting I go work on the outbreak and while at first I refused because of my teaching obligations, but my wife and consensus have reminded me that the teaching can be rearranged and postposed, but the outbreak intervention cannot.  I will be taking a 2 month leave of absence from Columbia University starting October 1st so I can work for WHO in Sierra Leone.

Thus, I am going to impose on your good nature and delay the start of my classes.

I am sorry if this disrupts your plans but I feel the need to be of some service at this moment when my limited skills will likely have something to contribute.  I look forward to seeing you in January.

Gratefully,

Les