By Dr Mo Yin
Associate Consultant
Division of Infectious Diseases
University Medicine Cluster
National University Hospital
After a 36-hour journey, I landed in Monrovia, the capital of Liberia. Instead of joining the queue for immigration and customs clearance, we were directed by health officers in gloves and masks to a dispenser filled with homemade bleach. Almost as if rehearsed, we washed our hands with no questions asked. It was February 2015. Liberia was in the midst of the toughest fight against an Ebola outbreak of unprecedented scale.
I had the unique opportunity to join the Global Outbreak Alert and Response Network (GOARN), a programme by the World Health Organisation (WHO), during this 2014-2016 West Africa Ebola outbreak. My mentors during the deployment, Professor Dale Fisher and Dr Sharon Salmon, are both infection prevention and control experts, and had already been on two successful missions to Liberia when I volunteered to join them. With advice and support from, the National University Hospital, residency committees and my department, my application was approved as part of my infectious disease senior residency training.
Tackling the last clusters of Ebola virus disease
We arrived just as a new cluster of Ebola virus disease (EVD) cases in one of the most populated sectors in Monrovia emerged. The WHO team worked closely with the Centres for Disease Control and Prevention (CDC), Médecins Sans Frontières (MSF) and more than 40 other non-governmental organisations (NGOs) to bring the cluster
under control. We adopted a ‘ring-fence’ approach, focusing on triage of patients presenting with symptoms of EVD, training of healthcare workers and providing supplies in high priority healthcare facilities in the sector.
Tackling an outbreak of this massive scale took multiple teams working side by side, including case management, epidemiology and contact tracing, burials and community engagement. The teams were made up of experts from various fields, from clinical medicine, to anthropology, to cartography. A seemingly straightforward issue of contacting primary care clinics took weeks because finding their locations proved to be a mammoth task as Liberia does not have street addresses and postal codes. Having diverse expertise from a wide range of backgrounds brought about strengths as well as inefficiencies and other challenges. These situations called for patience to listen, tact in communications and building effective teams, as well as speaking up and defending the facts. To consolidate efforts from the various NGOs and improve accountability, our team advocated for 50 minimum standards in infection prevention and control for all healthcare facilities across the country. I designed a web-based tool that allowed ‘live’ tracking of assessments performed on the needs and progress of each facility. This helped the team and local ministries to allocate and prioritise resources.
Our efforts were rewarded as this cluster of cases ended after four generations, with successively improved case mortality marking each generation.
Dr Mo Yin with colleagues.
Prevention of reintroduction of cases
With the number of EVD cases decreasing in Monrovia, we shifted our focus to the prevention of new clusters reintroducing from the Guinea-Sierra Leone-Liberian borders, where the outbreak first started. These areas are vulnerable as the borders are highly porous, and surrounding healthcare facilities are ill-equipped.
Given the limited period of time we had in these areas, we had to be innovative with our interventions. Six months after the Ebola outbreak was declared a Public Health Emergency of International Concern by WHO, infection prevention and control training had already been widely disseminated in the nation. How can we ensure our messages are delivered impactfully with a sustainable effect? To bridge the gap between classroom theoretical teaching and real-life practice, we decided to use simulation scenarios to assess local capacity and identify areas of improvement. Employing our drivers as potential EVD patients and ‘cooking’ vomitus out of biscuits and water, we put the healthcare workers and their systems to test. The experience exceeded all of our expectations. The healthcare workers were highly engaged and took intiatives in critiquing themselves and coming up with improvement plans. At the same time, we also came to appreciate the daily struggles of limited resources. A case in point: how do we expect compliance with hand hygiene when there is no water source nearby?
Breaking barriers
Inevitably, there were many barriers in volunteering for the West Africa Ebola outbreak. Concerns included fear of contracting and importing the disease, violating residency requirements, scheduling conflicts, family obligations, and lack of experience and maturity. There was a twinge of doubt over whether the effort and risks justified benefits for a first-year infectious disease trainee and the overall outbreak response. Together with my mentors, we built a case for an elective posting aligned to the WHO’s reform agenda of developing a global health emergency workforce. We designed a programme fulfilling all residency requirements in accordance to the Accreditation Council for Graduate Medical Education-International (ACGME-I) guidelines. Throughout the month, there was continuous supervision and mentoring with time allocated for reflection. The final evaluation was based on the concluding presentation of the team’s achievements to the WHO Representative for Liberia.
The volatile outbreak situation constantly posed challenges, both technical and interpersonal. An example was the need to negotiate with local health managers and partners to align everyone’s efforts and work with the inefficiencies inherent in resource-limited settings. However, these seemingly uncomfortable circumstances strengthened the experience gained in providing a holistic perspective in problem solving.
Many questioned the value that an inexperienced resident could bring to the task of helping to deal with an international outbreak. I found that a youthful outlook added diversity to an outbreak response team, along with fresh eyes, new perspectives and skills in information technology, social networking capacities and other web-based platforms. These provide practical solutions to challenges in communications, data sharing, and maintenance of key indicators especially in resource-poor settings. Trainees may also better connect with ground staff, and they can help in the implementation of policies and soliciting feedback.
The team’s work received commendations from both the WHO Country Office, Liberia and local leaderships. Upon return, the experience was shared with audiences including medical students, residents and senior doctors, nurses, and staff of the Singapore Ministry of Health. Stories from the field were widely deemed to add value to the Singaporean preparedness efforts.
Contribute with an impact
Aside from Liberia, I have been on short-term trips to China, Indonesia, Malaysia and served in local heavily subsidised clinics for foreign workers. A common theme drawn from these experiences is that making meaningful contributions is hard work. ‘Helping others’ is synonymous with breaking barriers and challenging the status quo. Add a dose of humility and willingness to observe, perseverance to excel, wit to spot an opportunity and a little luck to pull everything together. And perhaps the most powerful tool of all is the determination to serve.
About the author
Dr Mo Yin is an infectious disease associate consultant at National University Hospital, Singapore. She has been active in education, hospital administration as well as clinical research. Dr Mo Yin has an interest in multi-centre clinical trials, especially in antimicrobial resistance (AMR), and hopes to help build Singapore to be a regional leader in AMR research. She is currently based in Thailand, pursuing a PhD with the University of Oxford
References
1. Sivey, P. New funding models are a long-term alternative to Medicare co-payments. The Conversation. Available at: https://goo.gl/oofPBg.
2. The First Full Professor of Family Medicine Has Big Plans for Teaching and Research at NUS. Available at: https://goo.gl/eW5CwU.
Out in the field with fellow healthcare professionals.