Like people throughout the world, Cheedy Jaja, PhD, watched news reports last year about the horrors of the Ebola epidemic as it spread through West Africa. Trained as a nurse clinician and currently a health research scientist on the University of Cincinnati College of Nursing faculty, he felt the wrenching need to ease the suffering. A naturalized U.S. citizen, but originally from Sierra Leone, one of three countries hardest hit by Ebola, Jaja made the decision last fall to volunteer for a six-week stint caring for Ebola patients in his homeland.
"Sierra Leone is still my country,” he says, noting that he has lived in the U.S. for over two decades. "I felt that with my clinical and professional training, there was no way I could not do it. I just had to do something. My family was apprehensive, but very supportive, especially since my trip there was during this past Christmas. I told them I had to do it, and they noticed my determination.”
After contacting Partners in Health, a Boston-based nongovernmental organization, Jaja received approval from Dean Greer Glazer, PhD. "The College of Nursing was very, very supportive. They didn’t hesitate when I told them I wanted to go over to Sierra Leone to help with relief efforts,” he recalls.
Jaja originally expected to spend his time in Sierra Leone working on health policy, one of his areas of expertise, but the increasing number of Ebola victims forced the need for more clinicians so he agreed to work in an Ebola Treatment Unit (ETU).
"I’m glad I did it; it was a great experience. A very life-changing experience. I was also fortunate because I was able to work with clinicians from all over the world. Cuba, Liberia, Uganda, Nigeria. It was an international group of folks,” he says.
He attended a three-day Centers for Disease Control workshop in Alabama for clinical volunteers. The course covered the epidemiology of Ebola, clinical care and management, infection control, psycho-social health issues and instruction on putting on personal protective equipment, referred to as PPEs. Jaja had an orientation in Boston before he left for Sierra Leone on Dec. 20, 2014, and then three more-days of training in Freetown, the Sierra Leone capital where he was born.
A three-hour drive east of the capital and Jaja and his 14 colleagues arrived at Port Loko, a town of about 24,000 with a Danish Emergency Management Agency-constructed "tent city” and the Maforki ETU, a converted school complex. Despite being in one of the hardest hit Ebola areas, Jaja recalls that their living facilities were surprisingly comfortable. "Hot showers, daily laundry and good Danish food.”
Three more days of training and Jaja was prepared to spend the next five weeks working 10 hours a day, six days a week with Ebola patients. His first patient encounter however, "was a shock.”
"The first time I donned the PPE to go into the hot zone, I said to myself, ‘What was I thinking?’ It was really a life-changing experience,” Jaja recalls. "We walked into this ward and the first thing I saw on the floor was a female. She couldn’t be more than 28, 29 years old. She was half naked on the concrete floor. They get so hot from fever they just want to lie on the concrete floor because it’s cold. Kids would crawl out of their bed and lie on the concrete floor and take off their clothes. She was deceased. We covered her up and sprayed her (with chlorine). That was my first experience.”
For the next five weeks, Jaja and his colleagues worked in the ETU battling the physical exertion and the emotional toll of the work.
"It was difficult being around people who have no hope at all. You could actually tell a patient who was going to die. They have a blank stare on their face. There’s so much death and dying. It took all of us by surprise and we’re still dealing with the psychological trauma,” he says.
Jaja says the disparity between American health care and that in Sierra Leone is so great. He pointed to the lack of providing IV fluids to Ebola patients there. Fluid treatment is a standard of care for Ebola patients treated in the U.S. During his stay in Sierra Leone, fluid treatment finally became part of the treatment regimen.
One of the signs of Ebola is constant diarrhea. Patients at the ETU were defined by their diarrhea and loss of fluids. In the beginning, he recalls, it was just palliative care. That changed the second week he was at Maforki when IVs and antidiarrheals became staples of a more rigorous treatment regimen. Most of the patients there also had malaria, so everyone who came to the ETU was treated for both malaria and Ebola.
The ETU comprised six buildings, each with eight or nine beds. The daily census was between 20 and 60 patients. Each had completed a questionnaire to determine their symptoms and was asked if they had recently been to a funeral, as touching a deceased Ebola victim was a frequent transmission method. Patients were classified as "wet” (having diarrhea and vomiting) or "dry” and further divided into wards with suspect cases and confirmed cases. Positive Ebola PCR (polymerase chain reaction) tests sent people to the "confirmed” ward. Patients with negative tests were kept for three days and retested. They were discharged after a second negative test.
A vivid memory Jaja has is "donning” and "doffing” the PPE before entering the units.
"It was a hooded Tyvek suit, N-95 face mask, boots, theatre cap, three pairs of gloves, face shield and apron. It would take almost 15 minutes to put on. Everyone was assigned a buddy and each would check the other’s PPE to ensure it was put on properly,” he says. "Once the PPE was on we were labeled with our role—nurse, doctor, sprayer, hygienist, corpse team—our name and the time entering the unit because you could only be in the suit for no more than two hours.”
Two-member teams would go from the healthier patients to the sicker patients, assessing them, doing a physical exam, providing medications and fluids and encouraging them to drink as much as possible. Each clinician would be sprayed down with a 0.05 percent chlorine solution after each patient encounter.
When the two hours were up, they would follow a meticulous process of removing their PPEs. Each would be sprayed again with chlorine and systematically remove the suit knowing that most health care worker infections occurred because of suit removal mistakes. A final hand wash with chlorine and then soap and water completed the 15-minute process. "By the time you take off the PPE you are drenched. Your boots would be filled from your sweat,” Jaja says.
Everyone relished watching patients improve. But "sometimes robust-looking young patients would decompensate dramatically and unexpectedly. Sometimes a child’s family members would die around them while in the unit and we would worry about who would look after the child while still in the unit and how that child would fare if he or she were to survive. The low survival rate for children under 5 years was particularly hard to witness,” he says.
Another memory he has is of the 700-grave cemetery about two miles from the ETU and dedicated to Ebola victims. Workers typically dug 15 to 20 graves a day to keep up with demand.
Jaja knows he and his colleagues made a significant difference in people’s lives and helped keep many people out of the Ebola cemetery. He tries to remember the positive moments that came out of their work, recalling a day near the end of January when they were able to clear a ward of patients and another day when no new patients came to the ETU. "I never thought I would see something like that,” he says.
But then the patients started coming again.
There were celebrations when patients were discharged, a happy but elaborate process, Jaja says. Anything the patient brought with them to the unit was destroyed to slow disease transmission. Patients took what everyone called "a happy shower” and were given new clothes. The World Health Organization provided each person with a package that included a bag of flour, a gallon of cooking oil, cooking utensils, a mattress and blanket. They also received a certificate that declared them Ebola-free.
"I got to sign the certificates that said they survived and were allowed back into their community,” he says.
The patients’ last responsibility before leaving the ETU was to tie a ribbon on a tree indicating that they survived the virus. Then a team would drive the patient to their community where everyone was told that the patient could no longer infect anyone.
"People with Ebola often had their houses burned down. We needed to go with them so they would be accepted back into their communities. Families would dance with joy when they found out their family members were alive,” Jaja says.
Jaja returned to the United States Jan. 28 and spent three weeks in quarantine to ensure that he was not infected. He began teaching his students remotely first from Sierra Leone and then from his home during the quarantine period before returning to his duties at the College of Nursing. He’s happy to share his experiences with anyone who asks, especially his students.
"Everything seems so ordinary now. Writing a manuscript pales to holding the hand of a child, wiping her brow or removing that dead child from her bed. It does not compare.
"Each time I interacted with a patient, for the grace of God that could have been me. Each patient I treated, I told myself that I was treating myself. Empathy, compassion and the ability to make do with very little is so important. Being there was a value education and it taught me to incorporate these values into clinical practice with my students. I will pass these values onto my students.”
Jaja says what he saw during his five weeks at the Maforki ETU left an indelible image in his mind.
"Ebola strips individuals of all sense of dignity. There is something about it, it deprives you of your sense of humanity. That’s what I found most surprising. It was a miracle when someone survived. The impact of how the disease decimated families, that was hard for me. This loss of dignity is what really got to me the most.”
Jaja has no plans at this time to return to West Africa, but he is keeping a sharp eye on the situation.
"It’s just a matter of time before the Ebola cases get to zero. The number of new cases continues to drop and in many areas there is now a system in place to treat the disease. There also is much greater awareness of Ebola,” he says.
"I don’t think there will be a massive outbreak again in Sierra Leone like six months ago. But what’s needed is to strengthen their health care system. I want to emphasize that an epidemic like Ebola requires global effort. We need to realize that. I just wish that the crisis in West Africa was viewed in this country as our crisis, not their crisis.”
Cheedy Jaja, PhD, MPH, MN, RN, is an associate professor at the University of Cincinnati College of Nursing. He is trained in pharmacogenetics and currently conducts research into sickle cell disease treatment, pain management and health practices.