DAVID J. HUNTER: So you discuss the difficulties
as a health care provider-- hot environment, protective clothing that
is heavy and leaves you dehydrated-- so you can only work one
to one and one half hours at a stretch.
How difficult does that make the interpersonal contact
with patients and just the technical ability
to do things like put in an intravenous syringe?
RUPA KANAPATHIPILLAI: It's very challenging, obviously.
The clinicians and I think most of the staff that worked in the ETUs
would do their best to try to engage with patients in a way that
is meaningful, so basic things like writing your name above your goggles
so patients could identify you.
This became a big part of it.
People were so afraid of being infected, being stuck in an ETU,
watching their loved ones die around them-- terrifying.
So this became a big, very real practice for the clinicians.
This was to try to provide some human familiarity, contact with the patients.
In terms of doing procedures, it's incredibly challenging-- double gloves,
you're dripping sweat from every pore, people are hypovolemic.
This is incredibly challenging.
But you do your best.
You try to find a big vein.
You don't attempt until you feel comfortable.
It's incredibly challenging.
DAVID J. HUNTER: So some have pointed to the fact
that the survival rates were so much higher
in people who had contracted Ebola or were
flown to Europe or the UK or the US.
The numbers are a couple of handfuls.
But it's been said that if those facilities were available,
the case fatality rate could have been so much lower.
Is it really realistic to imagine that that
could have been provided at short notice and the ability
to lower the case fatality rate could have
been put in place with more modern or more sophisticated
ETUs supported from abroad?
RUPA KANAPATHIPILLAI: Again, there are several parts to this question.
I think what we know about-- what we've learned
from this outbreak is that factors that really contribute to mortality
include viral load at time of presentation and age.
So that's one part of it, and then accounting
for other things like co-morbidities.
So in the patients that were infected and then expatriated,
taken back to the US, to the UK, I think what
is important to remember is that they received a variety of interventions,
everything from mechanical ventilation to hemodialysis to a cocktail
of various experimental therapies.
It is hard to know exactly which of those interventions, combined with age,
co-morbidities, viral load, impacted their outcomes.
The second part of it is in the midst of an outbreak,
to be able to implement very sophisticated medical devices is
very, very challenging.
At the peak of the outbreak, there was just
a need to do very basic things like provide enough ETU beds.
I think yes, optimistically, we would say forewarned is forearmed,
and I think having things in place like point-of-care tests, really simple,
basic tools that can be used in a more widespread way in ETUs
would perhaps help change outcomes in future outbreaks,
if there are future outbreaks.
Things like more invasive means to deliver
intravenous or intra-osseous resuscitation,
the use of inotropes, mechanical ventilation-- some of these things
I think perhaps can be implemented.
Some of these things are, I think, not real.
They stick in the peak of an outbreak.
Again, weighing up safety and feasibility in an ETU setting,
I think, needs to be considered before we
talk in more detail about more sophisticated mechanical tools.
DAVID J. HUNTER: To say nothing about electricity and air conditioning
and the other factors that you'd need.
In the ETU, you have patients-- you've now
got a four-hour turnaround on the test.
How does one handle triage of who arrives,
who should be brought to the unit, who should be admitted,
and how do you deal with people with non-Ebola conditions,
but who are in urgent, acute need of medical care?
RUPA KANAPATHIPILLAI: So there is a fair system at emergency,
and the decision to admit someone to the suspect tent
is really based on an assessment of risk, so fever plus,
essentially, exposure.
So anyone that meets those triage admission criteria would get
admitted to the suspect tent or tents.
They would then, if they had been symptomatic for greater than 72 hours,
have a PCR test with a four-hour turnaround time that would
confirm yes or no, they were infected.
If they were infected, they would go into the confirmed tent.
Everyone that was admitted to the ETU would empirically
get broad-spectrum antibiotics and anti-malarials
to try to combat other common infectious diseases that may cause fever.
So that was standard practice in our ETU.
DAVID J. HUNTER: And people arriving with other treatable or social
conditions just have to be turned away because your folks don't
want a single disease.
RUPA KANAPATHIPILLAI: That's right.
So this is part of the complexity.
And one of the hardest things, in fact, is
the people that have other clinical problems-- pregnant women-- this
is one of the most tragic parts of at least my time in Liberia,
seeing pregnant women present who had been turned away
from multiple other hospitals because they were febrile,
they had exposure to Ebola.
So the concern was of course that they were infected,
and to have any sort of intervention with an associated enormous
transmission risk was not manageable in most
of the health care facilities in Liberia, at least at the time
that I was there.
DAVID J. HUNTER: And did that preexist the epidemic,
or did those hospitals essentially close or fail
to function because of the fear of Ebola?
RUPA KANAPATHIPILLAI: So I think it's more the latter.
Once again, these are countries that don't have particularly strong health
systems to start with.
You layer on top of that, really, the panic
and the fear associated with acquiring Ebola or treating patients with Ebola,
fear of transmission to others.
Health care in the country was essentially just shut down.
There were a few functioning facilities.
There was a referral hospital that we could refer patients to,
but for many, many, many months, health care facilities that were not ETUs
were completely shut down.
DAVID J. HUNTER: And this is a disease which
may be one of the highest-risk groups for health care workers.
I believe about 500 of the 11,000 people who died were health care workers.
So that impacts just the number of people available to help.
And what's the psychological impact for a health care worker
of knowing that and knowing that risk?
RUPA KANAPATHIPILLAI: I can't speak for everybody.
I think people's experiences have been quite varied,
at least the people that I know and continue to be in contact with that
worked in an Ebola setting in this most recent outbreak,
and their responses have been really across the spectrum.
For some people, it's been incredibly challenging,
and for others, they have continued, and it's just been completely manageable.
I think, of course, there is a concern of acquiring the disease, a fear,
of course.
In Medicin Sans Frontieres, it was very clear about rules and regulations
in the field to try to minimize risk and try to mitigate that fear,
at least within our health care workers.
DAVID J. HUNTER: So you've been in other difficult places with MSF.
How is this different from working in other crises?
RUPA KANAPATHIPILLAI: I have never quite experienced the level of fear.
And again, I can't speak for everybody, but the level of panic
I have never really experienced before in any setting.
I have never seen patients look so afraid or be so afraid.
I think that's probably the biggest thing, the fear of infection,
of even the smallest contact with people, things that we take for granted
everyday like shaking hands-- just completely absent.
And I had worked in HIV for some years before.
The only thing that I can possibly liken this to
is perhaps the bad old days, the early days of HIV exactly before treatment.
The other thing that I think has been disturbing about this
is the rapidity of deterioration of patients, hours to days as opposed
to months.