Blog: Nurse Practitioner Tackles Ebola in Liberia & How to Articulate the Magnitude of the Experience

UNC's Chris Evans, RN, ANP,BC, left, worked with Physician Assistant Sam, Senior Site Research Coordinator, on Ebola in Liberia.

UNC’s Chris Evans, RN, ANP,BC, left, worked with Physician Assistant Sam, Senior Site Research Coordinator, on Ebola in Liberia.

Chris Evans, RN, ANP-BC, works in UNC’s Division of Infectious Diseases. He traveled to Liberia to conduct research into treatment of the Ebola virus from March-June 2015.

4.0L V6 with more than 245,000 miles. That’s what my Jeep Cherokee has on it. I’ve had it for more than 10 years. A few weeks ago it broke down off of highway 40 near the RDU airport exit, complete with sound effects and pyrotechnics. It happened not long after I returned to the States. Its engine is beyond the practical scope of repair, so I’m going through the not-so-fun time of buying a car. I’ve test driven most every small truck and SUV out there and have had a fair amount of talk time with car salesmen while we take off on highway 40 and 540 to get the cars up to speed. One particular night I finally test-drove a car I had been eyeing for a while.

While cruising around Apex and Cary, still trying to adjust the seats and mirrors, I made small-talked with the salesman. He asked what I did. I explained that I was a nurse practitioner with UNC, squeezing in details between hearing about the features on the car.  After hearing about the 9-speed gear shifting I mentioned that my job had afforded me the opportunity to go to Africa.

“Where at?” he asked.

“Liberia, it’s in West Africa,” I said.

“What did you do there?”

“I helped with the Ebola efforts.”

“Oh,” he replied, followed by a half-joking, half-serious, “you didn’t bring Ebola back with you, did you?”

“No.”  We laughed it off and began talking about more features of the car.

I’ve mentioned it a few times to a few people that I’ve served in Africa, and I often find myself erring on the side of not wanting to go on in very much detail; as a generality, I don’t bring it up at all. It’s not that I don’t have anything to say; it’s just a very big story to tell, which is hard to sum up in the time it takes to get a car up to 60 mph. It’s also a story that can’t be separated from the dire reality that comes when working within a region of the world that has experienced a humanitarian crisis. It’s one thing to see it on CNN; it’s another to be there on the ground. I must’ve even tried 25 times by now to sit down and write this post, but I keep pausing before I start, pausing in the middle, pondering how to pick the best words to accurately reflect the magnitude of what has happened “over there.”  I have a finite amount of time to tell a seemingly infinite story.

As part of the continued research efforts guided in large part by UNC’s David Wohl, MD, and Billy Fischer, MD, I spent three months in Monrovia, Liberia. There, I worked at ELWA hospital providing support for the research efforts alongside the Liberian Ebola fighters and missionaries who served faithfully in the arena of chaos…they are all brave-hearted individuals with epic life stories.

ChrisEvansLiberiaStigmaTagWEBMarch 9th began with me eating airline food somewhere over the Atlantic aboard a Brussels Airlines flight. It ended with me weary-eyed stepping off of the plane, and once out of the airport, taking my first step onto the red dirt of Liberia. As I stepped on to Liberian soil I left behind all hand-to-hand contact and traded it in for fist and elbow bumps (the new custom to reduce Ebola transmission).

Each day was so dynamic, had so much to take in, but it didn’t take long before it felt like home, before the Liberians and missionaries felt like family. It was clear from the outset, this land is special. No, this isn’t the land of national parks sprawling with lions and elephants.  This is the land of community, sprawling with people.

As the sun begins to rise in Monrovia, the capital city on the coast, the fishermen begin working as large teams to push their boats out to sea. No motors here, just manpower and teamwork. They power past the breakers that stand up tall and curl over for the Liberian and ex-pat surfers. They’ll use their seemingly endless nets to bring back some of the freshest fish, crabs and lobsters you could imagine; these will get sold by locals who will carry them atop their heads in large buckets.

Each morning started with breakfast at our hotel. James was the hotel chef, a proud husband and father who walked 20 minutes from his home to catch a motorcycle taxi for an additional 50 minute ride to get to work. I would always place an order for three scrambled eggs and he would reply, “ahh, three eggs scrambled, yes.” His upbeat personality was always an encouragement during the early morning starts. His upbeat personality became so cherished towards the end of my stay when he also shared how people along the road would try to cut him with broken bottles during his trek to work in 4 am darkness to try and get what little money he had. And to see his iron will to strive for the future success of his children would make anyone sit up a little straighter on the job.

ChrisEvansLiberiaChildrenSchoolLineWEBAfter eating quickly we then met our driver, Emmanuel. He’s a young twenty-something with a muscular build who wants nothing more than to be a U.S. Marine. Our team (the ex-pat half) packed in to his Pathfinder and made the one-mile trip over to ELWA hospital. Traffic moved slowly while motorcycles leapfrogged cars with any gap they could squeeze into. Alongside the road it was common to see children lined up in their school uniforms facing the Liberian flags being raised in the courtyards, local vendors selling everything from phone scratch cards to food to cement bricks, children pumping water from wells, chickens scratching at the ground, and dogs running around playing as dogs do. The exhaust from the traffic quickly builds up with the rising of the sun. Horns are used less as a sign of anger and more as a way of life. Need to get someone’s attention on the road…horn. Horns, all day, every day. Junctions were also packed with people waiting to catch rides from anyone who had room to pick them up. Different hand waves are used to signal how far down the road you need to go; and once you knew what to look for, you could read the hand waves pretty easily. Upon reaching ELWA junction, we made a quick left turn and pulled up to the security guard who would let us in the gate. And while it’s a gate for cars, the compound is wide open to pedestrian traffic. But before entering the gate we would always make a glance to the left to wave at Tommy who both lived and worked just outside the gates. Always with a smile on his face, he made some of the finest wood creations from African mahogany. I had him make a few personalized items for me to bring back. He was putting himself through college with the money he made from woodcarving. After a short drive past the main gate, Emmanuel would pull up to the front entrance to drop us off.

ChrisEvansInsideBloodMobileWEBIt was hard not to notice the blood mobile sitting right in front of us as we opened the car doors. For starters, it’s big. But most notably, it’s a rather contemporary piece of technology in comparison to the hospital infrastructure that sits behind it. Aboard the bus, we can accommodate working with three Ebola survivors at one time. Not to mention it had the best air conditioning and internet signal to be found. The floor of the bloodmobile has seen more than a few tears fall to its surface as Ebola survivors have shared their stories. But trust me, we shared plenty of laughs aboard that bus. Darlington, Galakpai, and George are our lab techs that run the bus and collect the donations. Darlington is the social butterfly, always finding a reason to engage someone in conversation. Galakpai is the serious one – quiet, yet strong and determined. George is the newest and quite eager to learn, much like a young apprentice is eager to please his teacher. Each of these men has amazing life stories. They keep the operational portion of the research running.

Sometimes in the afternoon I would work with Korlia aboard the bloodmobile. Korlia is the president of the Ebola Survivor’s Association of Liberia, well-accomplished in his early 30s. By training he is a Physician’s Assistant (PA). Not a loud person, but very commanding of attention when he stands before a crowd. I partnered with him for several projects. He understands well the difficulties survivors have faced with stigma and has worked hard to advocate for survivors across the region.

The lines start early. Before entering the hospital, everyone is required to wash their hands with a bleach solution from the big barrel that sits out front, which makes for plenty of bleach stains on your pants. The triage team then takes your temperature after which you’re allowed to move on to your next station. Some will go on to sit in the waiting area to be triaged; some will have surgery; some will go to the pediatric clinic for treatment; some will go on to the survivor clinic; and some will prepare for labor and delivery.

I often got to the hospital early and ventured through to the back of the hospital for the 7:30 a.m. chapel service. To get there, it wasn’t uncommon to pass long lines of people seated along the halls waiting to be seen – mothers hold their children in their laps; the hurting clutch on to family members or their own bodies for some sense of support; surgical patients are prepped for their case; the medical teams round on their patients. It can often have the density of a mall around the holidays. It’s easy to notice the Islamic women who arrive completely veiled in their traditional black burqas, only their eyes visible.

When it rains, you have to be a little choosier about your steps around the hospital so as not to step into a puddle. The hospital is under constant renovation and improvement.  While I was there, roofs were being repaired and cement sidewalks were being added. Much credit goes to the renovation teams. They worked hard up on the roofs in the hot sun and sidewalks in the pouring rain. In fact, a new hospital in the adjacent field is being worked on as I write this. Unfortunately the outbreak put a halt on its construction with resources needing to be reallocated. But, with things calming down, teams are working quite hard to complete what will be a very nice new ELWA hospital.

ChrisEvansLiberiaChapelEWLA1WEBThe brick chapel with partial open-air sidewalls isn’t anything special in structure. It has several wooden pews. Those who attend hear a short meaningful message and celebratory singing. It is hard not to be moved by the singing. It is real and honest. At the end of each chapel service Dr. Brown, a native Liberian, is often invited up to the front to address the hospital staff.  The same man who appeared on the cover of Time Magazine, celebrated as [a] Person of the Year for his efforts [as an Ebola fighter] to take care of the patients in the Ebola Treatment Units (ETU), leads a humble, faith-led life. Soft spoken, yet very commanding, both approachable and willing to listen, he is a fitting Person of the Year. At the end of his daily address he pauses and prays. And while bowing your head, you might open your eyes and with a quick glimpse only see plane tile floors, nothing cosmetically special about them.  But if those tiles could tell stories, if the wind blowing through the open holes in the walls could be translated, oh the stories they could tell. For the story of the ELWA chapel is more than that of preaching and prayer, it’s one of rescue and care. The ELWA chapel was, for a time, converted into the first Ebola Treatment Unit in Liberia. The very floors that hold the pews and that we stand on to sing are the same floors that held people who struggled and fought for their lives during the early part of the epidemic. That was never far from my mind for all of the hours I spent inside of the chapel.

The Liberian Site Team: Gertrude, Korto and Evon.

The Liberian Site Team: Gertrude, Korto and Evon.

I would meet our team in the heart of the hospital where a small room was converted into our temporary office. As one entered by 8 a.m., it was common to see some of the site team there and working. Gertrude is the site coordinator; Evon handles the finances; Edwina is a nurse; Korto is a PA; and Sam is a PA and the senior site research coordinator. Novels could be written about what these people have seen and done. Sam and I, being about the same age and scope of practice, worked well together. He became a dear friend. On my final day, he held a ceremony to send me off in accordance with his tribal traditions. That meant a lot to me and I couldn’t have chosen or planned a better way to be sent off if I had to. The office was also joined with Dr. Fankhauser’s office.

A missionary doctor, John Fankhauser followed a path that led him away from California to a country that would call on him to be a key leader in the largest Ebola outbreak in recorded history. A man of strong character and integrity, he has a deep care and love for his patients, and his patients trust him. He is a strong advocate for the Ebola survivors and started the first Ebola survivor’s clinic. Again, so many stories of bravery and dedication could be told about him, but those are his stories to tell. If you have free time though, it’s worth reading about him. He is a brave man and he has my respect. I hope our paths can one day cross again.

The middle of each day could take on so many directions. Often times they involved working closely with Ebola survivors. So much focus has been on the ones who died that it’s easy to forget that so many have lived. A brief chat with any one of them, and you’ll realize that these people are special. Any one of them could tell you about their awful time with Ebola, about their dark time in the ETU, or how many family members they lost. It wasn’t uncommon for tears to start falling after talking about those things. But it also wasn’t unusual to see a common joy for life within them. One thing, though, will be very clear after venturing down that path with any of them…they are a strong, thankful, joyous, and special people. Many were united with a mission and determination to do whatever they could to not let Ebola show it’s murderous face ever again. I wish there were enough pages of paper to tell the entirety of every individual story. They truly are special people.

But you’ll also notice, after a while of being in the country, that there is still a looming sense of stress, a sense of PTSD for many. Trauma of that level, magnitude, intensity, and duration does not go away quickly.

Andy is from D.R. Congo. It’s common to pass him throughout the day. He comes for three-week stints to train our site team on the bloodmobile. Often times, I’d go for short walks with him around the compound to decompress and talk about the project, and more importantly, to talk about life. He is soft spoken, yet confident and unwavering. A solid guy. Every team should have an Andy.

The West Point Community in Liberia

The West Point Community in Liberia

Lunchtime often took us over to the cafeteria, which is a room to the side of the pharmacy.  We often called it “Alice’s” since the young girl who brought out the food is named Alice. You had your daily choice of white rice and something with it, whether it is potato greens, fried chicken, or dried fish. One thing you can count on, like rain in the rainy season, there will be rice for lunch. One of my favorite quotes came from Sam at Alice’s. “Alice, please bring me rice and chicken, without a side order of flies!” Flies were everywhere on the cafeteria tables (and your food if you let them). Much like a deer shakes its side to get rid of flies, you got in the habit of swatting at them to keep them away without even thinking about it. Just part of life…you make it work.

It was common to see markings of Samaritan’s Purse around the compound, whether it be a logo on some of the ETU siding or other equipment. I got to know a lot of the Samaritan’s Purse staff while I was there. They were a huge help in getting me acclimated to the area and helping me find some ex-pat community.  S.I.M. mission staff was also a huge help. They’ve been at ELWA for decades working with the community. They’ve made it possible for many in the area to get healthcare and an education.

Afternoons, much like the mornings, could take on so many directions. Sometimes I was called on to take care of regulatory items, like writing Standard Operating Procedures and completing case report forms. Sometimes, we had to work out technical problems on our bloodmobile. Sometimes we had to talk about the status of the project and recruitment.  Sometimes we had to work with the local IRB. Sometimes we had to work transatlantically (Skype becomes much less of a social media and much more of a required tool when working abroad). Of course, internet and electricity were subject to the occasional heavy storm and lightning that could knock out all power and send rain occasionally leaking through the ceilings. But that’s life and you make it work.

A diesel generator powers the entire compound, which is constantly needing attention and care. AT&T, Sprint, etc didn’t exist where we were. Mobile phones do. You add minutes to them with scratch cards. Five dollars a card got you some amount of time, but I could never figure out exactly how much.

One memorable quote came when we were trying to find a locksmith to open the lock on our new office space. We started asking our site team whom they would recommend.  Someone off to the side, with humor and all seriousness said, “anyone, most anyone around here can pick a lock.”  Very smile-worthy.

Ubiquitous are the little orange lizards that are everywhere. Everywhere. Sometimes they get so excited they run right in to your shoes. They sit on the rocks, hang on the trees, run through the fields, and run through the hospital. They are everywhere.

Emmanuel was usually out front to pick us up by 5 p.m. and take us back to the hotel where we’d grab dinner and hang out for a while, sometimes as a group, sometimes on our own.

ChrisEvansPicofLiberianTownWebOn the night of Easter Sunday, I found myself sitting on the beach having a conversation with three physicians, each from different groups, one from Canada and two from the US.  The conversation we had I won’t soon forget. One of them said they got an e-mail from a friend stateside and it simply said, “how is your time in Liberia, has it been fun?”

Looking at us, all sitting in the sand with waves crashing in 4/4 time in the background and moonlit mist surrounding us, she said, “Has it been fun? How do I answer that? You mean besides the 2-month-old that died this morning at my hospital despite trying so hard to save her, or the other child that will probably die tomorrow. Yeah, it’s been real fun.”  With a sense of gallows humor and understanding of the challenges we all looked at each other and laughed at the original question. While I did not participate in direct clinical care while there, it wasn’t uncommon for my friends who were, to be waging very tough battles to save lives with limited equipment and technology. The disparity of clinical care in West Africa is real, and we were sitting in the middle of it. It’s a big mountain to overcome, but it’s not insurmountable.

Liberia and the US are forever bound by more than just the Atlantic Ocean, the grip they have on each other in world history is permanent. Conditions there can be hard. But even though the conditions are hard and Liberia is a very poor region, you do find time to laugh. Poverty isn’t all about money. Poverty isn’t all about possessions. It may often in large part be more about relationships, or a lack thereof. And while many there do not have much in the way of money or possessions, most have a true and genuine joy and happiness through the communities they are a part of. While there I did find myself doing less busy “stuff” and traded that for being more busy knowing people well. Asking them the deeper and more real questions. This was life-giving to me as we can become relationally impoverished here in the states, not speaking to our neighbors, living false lives online for social support under the guise of digital courage. If you want something done there, you have to talk to someone as e-mail won’t get you very far.

I wish the circumstances had afforded me more time for closure before I left, to say a few more proper goodbyes and give a few more elbow bumps. But as it played out, the job required some last minute running around and with three hours to spare, I was scrambling to the hotel to grab my bags and make my flight.

My plane touched down at RDU on June 3. After a long flight I was tired. I wasn’t sure how I’d feel getting off the plane. I was prepared to cry; I was prepared to just be tired.  After deplaning I took the escalator down to the baggage claim and got my bags fairly quickly. A friend came, picked me up and took me home. I got back and turned my power back on and got readjusted to my home. It had been three months since I had driven down highway 40. The North Carolina air was noticeably cleaner than the Liberian air I left. Suddenly the water was safe to drink again. Suddenly it was socially acceptable to extend a handshake. No major threat of power outages. No malaria or typhoid to worry about. I could stop all of my protective meds. But the dear friends I made were an ocean away.

Chris, left, and Dr. Jerry Brown, a native Liberian who was named by Time Magazine as its Person of the Year in 2015.

Chris, left, and Dr. Jerry Brown, a native Liberian who was named by Time Magazine as its Person of the Year in 2015.

Coming back has been hard at times. Most of my time and life there happened within a relatively small radius, but it was a busy, complex, purpose-driven time. I never questioned my purpose there. I never questioned the bigger meaning of what I was doing.  I never questioned any degree of personal sacrifice. And I certainly don’t mean to romanticize the time there. It was professionally the hardest thing I’ve ever done. But it was some of the best-spent time I can recall. And I would do it all over again without reservation. Sitting at my desk doesn’t feel the same right now. I still have frequent memories back to my time there. I can see every turn of the hospital halls in my mind.  All of my friends there, I can see their smiles. The ETUs and some of their de-commissionings. While I have them in photos, I don’t need them to see in my mind the wooden and tin fences surrounding them, the guards and bleach stations at the entrances, the tents where so many people surrendered their lives and so many survived.  The ordinary people acting heroically in a humanitarian crisis…those memories are indelible.

The story of Ebola, the story of Liberia, the story of ELWA is a really big story. I am forever grateful to have perhaps been a part of one small letter of that very big story. But if I could encourage, as often as the name of Ebola crosses your mind, please think of the people who have been affected and the people who are still in the fight. They are real, as real as you and I. They’re sons and daughters, mothers and fathers, brothers and sisters, orphans and widows, continuing to live in what most from the Western world would observe as an unimaginably difficult situation and they still need our help.

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