By Key Corresopondents: Audrey Bicknell and Jiewon Lim
Summer of 2019 for two medical students from the National University of Ireland, Galway (NUIG)
Audrey Bicknell– After volunteering in a hospital in Tanzania in 2014, I was inspired to return to East Africa, and in May of 2019 I was on my way to Uganda. I spent four weeks on the maternity ward of a rural hospital in Western Uganda, overlooking the Rwenzori Mountains where the Democratic Republic of the Congo (DRC) border is located. My days were filled with ward rounds, assessing labour progression, monitoring delivery recovery, newborn evaluations, assisting in caesarean sections and countless vaginal deliveries. In my final two weeks, I volunteered for Reproductive Health Uganda at their sexual and reproductive clinics assisting in services from family planning to STI and HIV management.
Jiewon Lim– As a summer intern at Evidence Aid, an organisation that builds evidence collections to advocate evidence-based medicine in the humanitarian sector, I had the privilege of updating the Evidence Aid Ebola collection with the most recent systematic reviews from the 2013-16 West African Ebola Virus Disease (EVD) outbreak, anticipating the use for fighting against the 2018-19 DRC Ebola outbreak and future Ebola outbreaks. Currently, the Ebola collection holds 37 high-quality systematic reviews ranging from topics such as the assessment of health systems in affected countries to ethical guideline coherence of the Ebola treatment clinical trials.
Stigmatization; Stronger than the fear of infection
Audrey – On June 10th, I arrived at the ward and was greeted by a woman explaining that there was a suspected EVD patient on their way to our hospital. Due to the interlinked nature of the DRC and Uganda, we were advised by a family member of six individuals that were in contact with someone who died from EVD in the DRC. The family needed to be monitored for signs and symptoms, and during this time, they managed to escape isolation. With the ongoing outbreak in the DRC just 38 km away, many thought it was inevitable that the disease would cross the well-traveled border.
When the 4-year-old boy and his mother arrived at the hospital on a boda-boda (motorcycle) he had been cooled by the air and his temperature (37.6 C) was not flagged by the Ebola team checking temperatures and providing hand sanitation to all hospital visitors. The mother of the boy provided different names upon admission stating that she was a member of the local community and had not recently traveled to the Congo which was not true. As a result, a doctor and nurse came in direct contact with the child. When the child experienced an episode of bloody diarrhea, the medical team acted fast and suited up in proper personal protective equipment and took the child and mother to the isolation unit. In preparation for the EVD to spread, the World Health Organization (WHO) had deemed a nearby hospital in Bwera the treatment unit. The child and mother were transferred to Bwera, where unfortunately the child passed away. The rest of the week was filled with tension, vigilance, ring vaccines, and more suspected patients arriving.
When Kagando Hospital was first alerted of the suspected child on his way to seek treatment, many questioned why the mother and child crossed into Uganda. They may have crossed to seek ‘better care’ for their child. Since the disease is automatically associated with a stigma, patients and survivors are treated with hostility from their community.
Something that I found particularly interesting was how the people of Uganda and DRC viewed EVD. Among members of the community, false information about EVD is prevalent; some people believe the virus was either created by the government or by the international community. The lack of scientific education regarding how it’s spread has led to people believing that healthcare workers are the ones spreading the disease; as a result, numerous treatment facilities have been attacked. These misconceptions have proved to be the most challenging aspect of this current EVD outbreak and contribute to the ongoing outbreak.
Jiewon- A healthy local community engagement in managing epidemic outbreaks is inarguably essential, inevitable due to its high degree of association with the rate of spread and surveillance. In the case of the West African Ebola outbreak in 2013-16, the general population had divided trust among the public health system and traditional medicine (witchcraft). The fragile relationship between the community and the national health sector led the people to frame incorrect understandings of EVD, stigmatizing those who were infected in nearby surroundings such as families and school/ workplaces. Contact tracing (contact listing) as a tool of surveillance is highlighted by Saurabh (2017) and the success of this disease management method heavily relies on identifying the affected individual, assessing the state, and following up with the recovery which requires active engagement of the local community throughout the entire process.
The aftermath of the deadliest viral outbreak
Jiewon- During our meeting, there was an intriguing moment that had made both of us realize the beauty of diversity in opinions influenced by the disparities in circumstances and environment. The discussion was on the topic of the recent modification in stance by the WHO with regards to the EVD outbreak in DRC being a public health emergency of international concern (PHEIC). From the viewpoint of someone who has been working behind the computer tallying up systematic reviews that have been published over a span of twenty years, the announcement in July could have been done three months prior to when the outbreak was reported not to have been a PHEIC yet. Reasonably so, due to the DRC outbreak showing overlapping patterns with the early West African outbreak in rate of spreading/ mortality, weak health systems, and low-grade surveillance and research.
Audrey- It wasn’t until EVD had reached Goma, a city in DRC with almost 2 million people, that the WHO declared a PHEIC on the current Ebola outbreak. Prior to the confirmed cases in Goma, cases were only present in rural locations of DRC. With Goma being the capital of the North Kivu province and a transportation hub for both domestic and international travel it seemed obvious the declaration was needed. After having conversations with numerous people from Uganda in early June, one of the common reasons the WHO had not declared this sooner was in anticipation of the impact on trade and travel restrictions. For the over 600,000 Ugandans that are employed by the tourism and travel industry, their livelihoods would be directly affected by the probable drop in tourism.
Jiewon- According to Omoleke’s review, the decline in exportation of agricultural goods and withdrawal from participation in international events such as the Olympics or Hajj had significant socio-economical and psychological effects on the affected countries in both individual and national levels. For those who aren’t or haven’t been involved with the affected countries, it would be naive of us to form thoughts and opinions solely based on numbers and trends.
Evidence Based Medicine (idealism vs. reality)
Jiewon- Evidence Aid provides free access to systematic reviews and short summaries (also in French and Spanish) of systematic reviews. Acting as the link between the two ends of EBM- providing health care and generating evidence, Evidence Aid believes that the dissemination of relevant evidence resources fulfill our mission to bring evidence based practice even in the resource scarce regions. Despite receiving positive feedback and references of the distribution of the Evidence Aid Ebola collection, we continuously work under the assumption that the resources will be utilized in places where it is most needed, thereby informing programmes and saving valuable resources.
Audrey- Fear was a common emotion among the public that EVD was rampant in their community as well as among the health care workers working in the hospital. When a resource limited hospital is struck with an EVD outbreak, many guidelines are difficult to follow. Each ward only had a few bottles of near empty hand sanitizer and a limited supply of gloves. As per WHO guidelines, contacts are not to be isolated until they show signs and symptoms of EVD and are able to continue work. This caused an outcry among hospital staff as they didn’t think the contacts should be working in outpatients with the risk of missing a sign or symptom and potentially contaminating hundreds of new patients. The hospital administration listened to the fears and gave onsite housing to the two contacts. When hospitals are given guidelines for outbreaks, everyone must act quickly and give all members as much information as possible in order to maintain trust within health care workers and the community.
Final words by Audrey and Jiewon
The 2018-19 EVD outbreak in DRC is a tragedy to the people of Congo and surrounding countries. We were fortunate to see and understand the complexities of this ongoing crisis with our own eyes, speaking to the experts, and through the published literature. We hope that our experiences and skills we acquired over the summer of 2019 will be valued throughout our future careers as physicians and be transferred to help provide the best evidence-based health care to our patients.
About the authors;
Jiewon Lim: Jiewon initially started her work at Evidence Aid as a volunteer and became the intern of the Evidence Aid Ebola collection. She was connected through Irish Forum Global Health (IFGH), working as a Student Outreach Group (SOG) representative of National University of Ireland- Galway (NUIG), whilst studying Medicine.
Audrey Bicknell: Audrey is currently in her third year of medicine at the National University of Ireland, Galway. She has interests in global health and women’s health and hopes to pursue a specialisation in Obstetrics and Gynaecology.