Send a Medical Team to West Africa

IMA Advance Team Preparing to Deploy to Sierra Leone

International Mutual Aid's advance team has completed pre-deployment training, and visas and tickets have been arranged.  We will deploy December 30.

We be operating in Sierra Leone for several months.  Check back in for pictures and stories from our response.

IMA is now a 501 (c) (3) organization!

International Mutual Aid has received expedited approval by the IRS as a 501 (c) (3) organization!

Ebola: The Mutiplier Disease

In early November, as only a handful of international medical NGOs responded to the World Health Organization's predictions of exponential Ebola spread in West Africa, a small group of medical professionals in their 30's founded a new nonprofit group to fight the disease.  Follow IMA's story, from conception, through the incorporation/501c3/formation process, to advance team deployment to West Africa and work on Ebola, on my new blog:

Ebola: the Multiplier Disease: Taking out Healthcare Systems

http://internationalmutualaid.blogspot.com/

Ebola Heroes: Dr Ameyo Adadevoh

The Doctor who stopped Ebola in Nigeria.
Nigeria is a country of 170 million, 3/4 of whom live on less than $2/day.  Nigeria's health care system was not prepared to handle Ebola, but fortunately the disease was stopped by the clever intervention of one doctor: Dr Ameyo Adadevoh.

In August 2014 an international traveler arrived in Lagos, at a time when all federal hospitals were on a labor strike. He collapsed at the airport, and due to the similarity between the general symptoms caused by Ebola and many other diseases, he was misdiagnosed with malaria by the first doctor he saw.  The following day Dr Adadevoh, who had never seen an Ebola case, suspected EVD and ordered a blood test.  She insisted on keeping the patient isolated, even while under pressure to release him so that he could attend an ECOWAS conference.  The patient's test came back positive for EVD.  There was no functional isolation ward in Nigeria, so Dr Adadevoh created one in her hospital.

Through this surprise exposure to an EVD patient, Dr Adadevoh and several of her coworkers became infected.  Dr Adedevoh succumbed to the disease on 19 August 2014.

Due to her early action, Ebola in Nigeria was halted at 20 cases.

Photo from "Remembering my Aunt, Dr Ameyo Adadevoh, who stopped Ebola in Nigeria" http://www.nytimes.com/2014/10/17/world/africa/because-of-ebola-ambulance-work-in-liberia-is-a-busy-and-lonely-business.html

Ebola Heroes: Foday Gallah

Monrovia Ambulance Driver, Foday Gallah, featured as one of Time's People of the Year: Ebola Fighters: 

"You don't want to know what Ebola feels like. If you're not psychologically strong and God is not on your side you will drop before you are taken for treatment because the pain is too great... I had known I would get it eventually. A lot of great doctors and nurses on the front line have died. They tried to be careful but Ebola still got them. I had carried so many patients in my ambulance and seen so many die in my arms... "

"I was {in the ETU] for two weeks. In the same tent as me in the treatment centre, a two-month-old baby died from the disease. And I lay listening to a lady who cried until she died..I don't know why I survived....I went back to my job, part-time, at the beginning of December...Now, ambulance crews are working 24 hours a day. When people are dying you need to be all over the city. It's hectic, our workload has tripled and we don't have enough ambulances in Monrovia to deal with the disease....Most of my friends now stay away from me because of my job."

Quoted from BBC News "My Fight Against an Invisible Enemy" http://www.bbc.com/news/magazine-30418759

Ebola Heroes: The Teenagers of A-LIFE

Even as Ebola raged through the seaside Monrovia slum of West Point, many residents denied the existence of the disease.  In August, dubious crowds broke into a West Point Ebola holding center and "freed" the patients inside.  Many residents believed Ebola did not exist, at least not in West Point, and that perhaps the entire outbreak was a fabrication, made up by agents who wanted to steal funding, harvest organs, or conduct experiments on humans.

But on Sept 17, a group of 200 teenage girls, and some boys, marched through the tight streets of West Point, promoting Ebola education through song.  This was the official start of A-LIFE: Adolescents Leading an Intense Fight Against Ebola.  This drive for public education, the name, and the organizing of A-LIFE was all done by Liberian girls age 16-19.   The girls of Liberia, a country with extremely high rates of sexual violence, are no strangers to hardship.  Yet in West Point, they were leading public education efforts.

After learning of the girls' efforts, local UNICEF leaders provided them with safety education and basic PPE.  It is likely that ongoing public education efforts such as this are responsible for the dramatic decline of Ebola cases in Liberia.

Well done, A-LIFE members!

Photos from UNICEF, http://www.thedailybeast.com/articles/2014/10/29/meet-the-liberian-girls-kicking-ebola-s-ass.html

Ebola Heroes: Gordon Kamara

During the peak of the Ebola epidemic in Liberia, when ETUs ran out of space and patients died outside, waiting for beds, Gordon Kamara continued his work as an Ambulance Nurse in Monrovia.  He worked on one of only 15 or so ambulances covering a city of ~1 million during a public health emergency.  At times he arrived at the ETU with a patient, only to be turned away because there were no beds available.

Mr Kamara also worked as a combat medic during the long Liberian civil war.  "“It is nothing compared to this, The bullets you can get away from. Ebola is hidden within our own families.”

Mr Kamara has isolated himself from his family for their protection.  “It’s a very lonely virus... Not just for me, but for the entire country. We are all together, but all alone.”

Quotes and picture from NYTimes "Ambulance Work in Liberia is a Busy and Lonely Business"  http://www.nytimes.com/2014/10/17/world/africa/because-of-ebola-ambulance-work-in-liberia-is-a-busy-and-lonely-business.html

Ebola Heroes: Dr Martin Salia

Dr Martin Salia died on 17 November in isolation at the Nebraska Medical center.
Dr Salia was one of only 5 or 6 surgeons in the entire country of Sierra Leone. His wife and 2 children are US citizens, but instead of pursuing a lucrative private surgical career, Dr Salia returned to Sierra Leone to help his country. He worked long hours as surgeon and chief medical officer at Kissy Hospital in Freetown. He spent his free time putting in additional surgical time at the Connaught Hospital and Davidson Nicol Hospital in Freetown and lecturing at the University of Sierra Leone medical school. He only saw his family in Maryland a few times a year.

 
Had Dr Salia successfully pursued US citizenship instead of returning to his native country to assist people there, he would not have been exposed to Ebola.  Had he stopped treating patients, as many of his compatriots have, he might not have contracted Ebola.  Had Dr Salia been a US clinician volunteering with an international NGO, he might not have detected his own infection earlier, but he would have had a clearer medevac path, and his widow would not be left with a $200,000 medevac bill.

Here's to the surgeon who stayed, in the face of a disease that tears apart families and turns communities and nations against those who should be loved and remembered as heroes.

Pre-Deployment Training at the CDC

Our first group of volunteer clinicians completes pre-deployment training for Clinicians Responding to West Africa, at the CDC.

Sending Clinicians to Treat Ebola Patients: Risks and Benefits

In an October 24th analysis, the New York Times reports that MSF has sent 700 doctors and aid workers from around the world to Ebola-stricken countries.  Of these 700, 3 have been infected with Ebola.  This means that each of those 700 volunteers had a chance of infection of 0.4%.  All three infected MSF expat clinicians recovered.  In fact, the death rate amongst EVD patients who have received Early, comprehensive supportive care in the developed world is near zero.  MSF has not been prompted by the risks involved to abandon their patients in West Africa, and we feel that this is the right decision.  Per the example of MSF, IMA will be seeking to better understand how transmission is occurring, and will be taking every possible measure to insure the safety of our clinic workers.

Allowing Ebola to become a permanent endemic disease in West Africa would create a much greater risk and expense than sending expat clinicians over to work in ETUs does.  If Ebola becomes endemic, hospitals in each affected country will have to consider every patient presenting with general illness will be a potential Ebola case- forever.  Initial triage/treatment of each of these cases would expose a number of unprotected clinicians to potential infection.  In West African settings, where many clinicians cannot even afford to use Basic Precautions PPE, this would make providing basic healthcare either horribly dangerous, or impossibly expensive.  In the US, any patient traveling from West Africa, with general illness symptoms, would have to be treated as an EVD patient until proven otherwise- forever.  To give some insight into the costs this would create: 1 MSF-style suit of PPE costs ~$80 and can only be used once.  This $80 does not include the PAPR recommended by the American Nurses Association.  Every ambulance, clinic, and hospital with potential for coming in contact with an EVD patient would have to keep unexpired stocks of this equipment on hand, and donning this PPE is only the first step in the isolation/treatment process. Imagine all the funding that would be pulled away from other medical programs, just by this PPE requirement.

If the current EVD wildfire in West Africa is not extinguished, but instead is only banked down to a slow endemic smolder, there will always be a threat of a spark traveling to a transit center in a large developing country.  Imagine Ebola in the slums of Rio, Mumbai, Lagos, or Jakarta.   Airport detection measures are notoriously unreliable, and there will not always be a clever Dr Adadevoh to provide an early, correct interpretation of the vague symptoms of Ebola.

The West African Ebola Epidemic is the first great epidemic of the Age of Globalization.  It is safe to assume it will not be the last, nor the most frightening.  It is safe to assume that not every epidemic will occur so far away from America.  The International Community's response to this public health emergency will set the precedent for future responses.  In the history book of the future, will our children read that we acted with courage and compassion, and sent in teams to treat patients?  Or will they read that we stood back, full of fear and indifference, and watched as a country collapsed and a new deadly disease became endemic?

Ebola: The Multiplier Disease: Taking Out Healthcare Systems

Ebola is a disease of poverty, but it is different from other diseases of poverty such as cholera and lassa fever for one important reason: Ebola takes out healthcare systems.  Millions of deaths occur every year from various diseases of poverty, but these do not make the news the way EVD does.  This is because a single cholera patient does not have the potential to shut down an entire clinic.  5000 people die per year of Lassa fever in the same area that is now affected by Ebola.  However, those 5000 Lassa deaths do not shut down an entire nations' schools and hospitals; 5000 Ebola deaths did.  
Ebola deaths have a multiplier effect.  Every Ebola death indirectly leads to dozens of deaths from unrelated conditions that go untreated due to hospital closures.  As vaccination programs are suspended, each Ebola death leads to dozens of deaths from vaccine-preventable illnesses.  As markets, schools, and developmental programs are closed, each Ebola death leads to lost opportunities, general weakening of systems,an increase in the potential for political instability, and food shortages.

Why Should the United States Feel a Duty to Help West Africa Fight Ebola?

Most people think of America as the antithesis of a colonial power.  But in fact we did have a sort of colony in Africa.  During the mid-19th century, the American Colonization Society moved ~13,000 American settlers to a colony on the  Liberian coast.  This effort was publicly supported by American political giants such as Abraham Lincoln, James Monroe, and Henry Clay, and it received public federal funding.  The colony site was scouted out by a US Naval Vessel, the colony organized itself under US Laws, and it adopted a Constitution based on that of the US.  Today an estimated 5% of the Liberian population is descended from settlers that came from America.  This is why you hear place names in Liberia such as Monrovia (named after President Monroe), Maryland County, Buchanan, and the JFK Medical Center.  If any independent country in the world has strong enough ties with the US to hope for assistance during an emergency, that country is Liberia.

Ebola has historically occurred in very rare, self-limiting outbreaks, mostly in rural villages  in Central Africa.  A key difference in the currrent Ebola epidemic is that it is spreading in crowded, poor, urban areas.  The conditions that are present in Liberia are mirrored in many, many other poor urban areas in Africa, Asia, South and Central America.  At the current caseload of 18,000 - 40,000, Ebola has already spilled out of Guinea, to Sierra Leone and Liberia, and thence in limited quantities to Nigeria, Senegal, Spain, the US, and Mali.  During the early phase of the epidemic, unimpeded by effective international intervention, the disease spread exponentially.  In Sept WHO reported that since May 2014, the number of new cases of Ebola has been doubling every 20-30 days.  In September the CDC put out a worst-case scenario projection of 1.4 million cases by January. 

IMA Fundraising Campaign on Indiegogo

Help Send IMA's Medical Team to West Africa - our Indiegogo Fundraising Campaign is Live!

International Mutual Aid is a Maryland nonprofit, founded in response to the Ebola epidemic in West Africa (EIN # 47-2251946).
 
Please help us publicize our organization and fundraise by visiting our kickoff campaign on Indiegogo at http://igg.me/at/ima    There, you can view our video, read about our organization, donate funds, and share our campaign using Share Tools for Facebook, Twitter, and Email.

So far, we have raised 27% of our goal of $20,000 during the first 24 hrs after launch.  Please act as an Ambassador for IMA - share our campaign and help us reach our goal!

IMA's website is http://www.im-aid.org

Help us stop Ebola!

International Mutual Aid, founded to provide direct patient care in West Africa

Hi all, haven't been here in a few years, I'm surprised how much the page views have jumped.  Glad you all enjoyed this blog/found it useful.

My travels in the south have been put on home and I am here in the US again, becoming inextricably caught up in the crisis response to West Africa. 


On to the next:


As many visitors here know from first-hand experience, the world has become increasingly integrated and globalized.  Some of you may have been affected in your work and travels by trans-border issues from piracy and conflict to diseases such as Swine Flu and MERS.

Now we are in the midst of the first great epidemic of the Age of Globalization.  As of 29 Oct 2014, the World Health Organization has a reported Ebola case total of 13,567.  WHO estimates that if unreported cases are taken into account, the total cases may be closer to 25,000.  Ebola has an average 70% death rate during the current epidemic.

The Ebola epidemic has caused nearly all medical NGOs to pull out of the three affected countries of Guinea, Sierra Leone, and Liberia.  In Liberia, even the local health care system that used to handle routine illnesses has collapsed.  For the first time in its history, the US very nearly saw a legal precedent set for forcible quarantine of a healthy individual.  Proponents of forcible quarantine openly admitted this measure was based not on science, but on public fear.  For those of you who are away from home, the popular response in the US is well summarized in the decision by Maine Judge Charles LaVerdiere, who struck down the forcible quarantine of Kaci Hickox: "The court is fully aware of the misconceptions, misinformation, bad science and bad information being spread from shore to shore in our country with respect to Ebola,” the judge said. “The court is fully aware that people are acting out of fear and that this fear is not entirely rational. However, whether that fear is rational or not, it is present and it is real."

I feel it's safe to assume that this will not be the last, nor the greatest health challenge posed by the Age of Globalization.  At present our response to this epidemic, both emotional and material, does not bode well for future crisis response.  

One primary response component currently lacking, which very few organizations have stepped up to offer, are trained medical personnel willing to treat patients in West Africa.

This is why I have joined with a group of emergency medical professionals to found International Mutual Aid.  IMA is a nonprofit NGO which be sending a group of medical professionals to operate a clinic and provide direct patient care in Liberia.  IMA is coordinating with the Liberian govt, on-the-ground NGOs such as Project Cure and PIH, and WHO to tailer our response to current needs.  Our fundraising campaign begins Nov 4 and we aim to have an advance team on the ground in November.

IMA is a small, flexible organization.  It was founded with the express purpose of advocating for patients and providing a courageous, humane response to this international public health crisis.  Much of the funding that we raise will be matched by larger NGOs who are providing supplies and logistical support.  If you donate to IMA, not only will your dollars make a direct impact on the amount of patient care available in Liberia, they will do so through a multiplier effect.  We will remain in Liberia to assist in rebuilding the local healthcare system after the epidemic peaks and wanes.

Please help us to stop Ebola!  Help us take action in the face of fear.  Every donation is a step closer.

                                                    
                                                              www.im-aid.org


Our fundraising campaign will commence on Nov 4.  To increase visibility, we will kick off with an Indiegogo crowdfunding action, then move to direct individual and corporate donations.

Thank you,
Virginia Price, Board of Directors, International Mutual Aid

Why Should I Care about Ebola?

I live in Maine.  I live in a beautiful, peaceful, orderly place where people pride themselves on their willingness to help their neighbors.  When I'm not putting in a 100-hour work week, I'm off hunting, renovating my old colonial home, or restoring my 1965 Pearson Vanguard.  Why should I care about a disease in West Africa?

Believe me, I would like to be able to ignore the troubled places of the world and just enjoy my life and my family here in America.  After all, that is what my parents got to do.  Unfortunately the technological advances of this century are eroding that privilege.  Whether or not I want it or agree with it, Mainers and Americans are no longer isolated.   Much of the equipment I work with is made from materials produced overseas.  When our ambulance is called to our weekly drug overdose call, it is the result of what's wrong in Mexico and Central America as much as what's wrong in the US.  At the 9/11 ceremony every year I am reminded that when segments of other people's societies become psychologically sick, they are often willing and able to reach out and harm American civilians.  I turn on the news at the station and it's a barrage of images of suffering.  I try to ignore them but they stick in the back of my mind.  We go on a call and the patient is coughing; we have to go through Swine Flu protocol at the hospital, or we have to decon the entire back of the ambulance to prevent spreading Enterovirus.   Now, we are developing special protocols, stocking extra PPE, and asking all our febrile patients if they've traveled to West Africa.  We talk about Ebola, we joke about Ebola, we answer the public's questions.  In the past months Ebola has become our constant companion.

Isn't it all hype?  Won't the epidemic burn out like past Ebola outbreaks?

I certainly hope so.  Our organization does not expect that to happen in the short- and medium-term for the following reasons:  First, past instances of Ebola were outbreaks, not epidemics.  It is a difference of scale.  Before 2014, the largest-ever outbreak of Ebola infected a total of 425 people.  As of 12 Dec, this epidemic has infected over 18,000 people according to WHO's Reported Cases count.   WHO estimates large-scale under-reporting means the real number may actually be closer to 30,000-40,000 cases.  Either of these numbers represents the first great epidemic of an acute, deadly, infectious disease seen during the Age of Globalization.

Second, location.  Past outbreaks generally occurred in villages and rural settings.  This epidemic is raging through cities, through some of the most crowded and impoverished areas of the African continent.  Liberia and Sierra Leone are recovering from long civil wars.  Widespread lack of access to infrastructure, health care, and education, distrust of government, and cultural traditions are all contributing to the spread of the disease. 

 

That's sad.  My country has its own problems.  I don't know anyone from West Africa. Why should I care about West Africa?

I believe that you cannot force change on people.  Whether it is my cousin who is fighting an addiction, my neighbor who is fighting for her civil rights, or my fellow healthcare worker in Mexico who is fighting to keep a hospital funded... the primary motivation and workload needs to come from the affected party, not from an outsider.  I will give my cousin, my neighbor, or my professional ally all the help that I can, but only if they are doing all they can to help themselves.

I want to help West Africans because I admire them.  Over 600 health care workers have been infected in the epidemic, largely due to lack of safety equipment.  Yet nurses, doctors, ambulance workers, and body recovery teams continue to do their jobs.  Liberian nurses receive just $500/month in compensation.   Contact tracing and public information teams head into affected areas, often with little protection.  They risk becoming fatally infected and leaving their families with no means of support.  Many of them have not been paid in months.  They are often stigmatized by neighbors and family due to their work.  Yet they continue to make their vital contribution; often inspired to do so because they have lost someone they love to Ebola. 

The news is full of truly inspiring tales of heroism in West Africa.  Gordon Kamara, a Monrovia ambulance driver, has isolated himself from his wife and children to protect them and has seen them only a few times in the past 5 months.  He drives one of only 15 or so ambulances that cover a city of 1 million.

Foday Gallah, another Monrovia ambulance driver, went back to work soon after being infected with EVD, suffering horrible pain, and watching others die in fear and pain in the ETU. 

In August, a key study on changes in the genome of the 2014 Ebola strain was published in Science.  Unfortunately, 5 of the 50 co-authors of the study died of EVD before the study was published. 

Dr Martin Salia, one of only 5 or 6 surgeons in the entire nation of Sierra Leone, dedicated nearly all his waking hours to treating patients and teaching in Freetown.  Dr Salia was married to a US citizen, who lived with his children in Maryland.  He had every chance to pursue US citizenship and a lucrative career in America.  Instead Dr Salia dedicated himself to bettering his home country, continuing to perform general surgery in Sierra Leone in the midst of a public health emergency.  In Nov 2014 he contracted Ebola, was medevaced late in the course of his illness, and died in isolation in Nebraska.

Nigeria is a country of 170 million, 3/4 of whom live on less than $2/day.  Poverty, crowded, impoverished urban areas, and political instability make Nigeria extremely vulnerable to epidemic EVD.  In July an EVD patient flew to Nigeria and presented with nonspecific symptoms at a local hospital.  After evaluating the patient, Dr Stella Adadevoh ordered an EVD test, which was positive.  Dr Adadevoh and several of her staff contracted Ebola and succumbed to the disease, but Ebola in Nigeria was halted at 20 total cases, due to Adadevoh's crucial recognition of the disease.

Local healthcare systems received a terrible blow, starting early in the epidemic.  Several of the country's leading doctors and researchers fell victim to the disease they were trying to stop.  Yet West Africans haven't given up.  They are still taking heroic measures to try to help themselves.  No country can fight a disaster of this scale alone, and I think West Africans have earned our help.  IMA will be focusing on enhancing West Africans' demonstrated ability to help themselves by hiring and training talented locals to assist us as frontline healthcare worker staff.

​

International Mutual Aid's Mission

International Mutual Aid is a nonprofit organization started by a group of medical professionals.  We are coordinating with local government, WHO, and involved Non Government Organizations (NGOs) to provide direct medical care in West Africa.  This is a rapidly evolving situation which demands flexibility and willingness to adapt to realities on the ground.  With that in mind, our provisional treatment model is detailed below.

Due to the magnitude of the epidemic, losses of local clinicians, and collapse of local healthcare infrastructure, there is an acute shortage of trained clinicians in West Africa.  The current Expat Clinician-intensive care model is expensive and difficult to sustain long-term.  Control measures have so far successfully reduced cases only in Liberia; EVD is unlikely to be eradicated from West Africa in the near future.  Our goal is to augment current efforts against EVD in West Africa by mobilizing civilians to assist in patient care.  Properly trained civilian healthcare providers are already used with great success in various sorts of underserved areas: examples include EMS systems worldwide and Last Mile Health in Liberia.  In the US, soldiers are trained to start and maintain IVs and IOs during an 8 hr course.  During a disaster situation, with similar accelerated training, appropriate supervision, and ongoing education, civilians are capable of providing care such as IV maintenance, cleaning, feeding, and moving patients.  In every town in America, EMS technicians - often civilian volunteers - extend the reach of the doctor far beyond the hospital, by implementing standardized treatments under his direction.  While it takes a doctor to diagnose and treat the myriad tropical diseases that are seen in the West African setting under normal conditions, it is IMA's belief that the EMS Model can be used to provide treatment for a single epidemic disease such as EVD during a public health emergency.

IMA is deploying a small team of expat clinicians who will train, equip, and lead a team of local frontline healthcare workers (FHWs), most of them non-clinician civilians.  With careful supervision, working alongside our expat clinicians, our FHWs will assist in providing basic supportive care to patients in a CCC-scale isolation unit.  The team will work under the supervision of a single physician Medical Director and a small number of RNs and/or Paramedics.  IMA will focus on EVD treatment until the epidemic is brought under control.  After this, IMA plans to establish an expanded training and support program, to allow FHWs to provide access to basic medical care in their villages.  

IMA will use a standard EVD treatment protocol: MUST. For IMA’s purposes MUST- Maximum Use of Supportive Therapy- consists chiefly of oral and IV rehydration, treatment of secondary infections (antimalarials/antibiotics), and transfer to a higher care facility when possible.

Though the Ebola response is accelerating, many areas of Sierra Leone remain underserved.  CCCs are designed to promote local access to EVD care, but they can become foci of transmission if not properly managed.  IMA will ensure that our CCC not only limits EVD transmission, but also improves patient survival, through the following:

1) Engineering controls: Promoting effective isolation of non-confirmed EVD cases through facility layout and regulating movement of patients, visitors, and health workers.  Ensure supply and correct use of PPE.

2) Leadership: Our expat clinicians will provide careful training, supervision, and ongoing re-inforcement of proper PPE use and correct technique for basic patient care skills.

3) Treatment Protocol: Define a simple MUST Protocol that can be carried out safely and uniformly, using minimal imported personnel.

It is our hope that our treatment model will offer a realistic way of getting as many patients as possible into Ebola treatment centers early.  We believe this is the best way to slow the spread of Ebola - a disease which has shut down the healthcare systems of several nations, and may become a permanent endemic issue in West Africa.  Getting patients into treatment centers improves their survival chances, frees them and their loved ones from the fear of spreading the infection, and insures them compassionate, non-judgemental care.

Availability of treatment for health needs other than Ebola has plummeted.  One of our primary aims is to reduce the burden on multi-purpose hospitals and clinics, allowing them to resume their normal mission of treating complications of pregnancy, trauma, heart attacks, malaria, typhoid, and much more.  As the epidemic is brought under control, IMA will shift our focus to supporting efforts to rebuild local healthcare systems and reduce susceptibility to future outbreaks of Ebola and other epidemic diseases.

IMA will be conducting all of our emergent-phase operations with an eye to laying the groundwork for long-term solutions. The final shape of the outbreak curve remains a mystery, and prolonged low-level transmission may result in ongoing shortage of general medical care in affected countries. West African healthcare systems, already weak, have been dealt a heavy blow by Ebola.  Even before the epidemic, Western-level access to healthcare was many years away.  While the long-term goal is a physician-/hospital-intensive, developed-world level of care, right now West Africa needs healthcare models that are functional in current conditions.  Last Mile Health in Liberia is setting an excellent example of such a system.  IMA’s long term goal is to train and organize existing talents, and to partner with existing healthcare providers, to build a similar frontline healthcare organization in underserved communities of Sierra Leone.  Specialized Ebola training is only the first step.  Frontline health care workers, fully trained to practice in their own villages, can do an enormous amount to link villages to regional clinics, and to prevent, diagnose, and treat myriad health issues.  Potential village-level care includes healthy pregnancy support, childhood immunizations, ensuring compliance with treatment regimens, identification of patients in need of higher care, initiation of patient transport, and frontline control measures against malaria, pneumonia, meningitis and much more.  Additionally, frontline healthcare workers will be in an excellent position to identify and help control any future Ebola outbreaks at an early stage.  Community-sourced FHWs, familiar with traditional practices and fully integrated into local social and power networks, are perfectly placed to provide a bridge between the village and regional clinics.

While our FHW selection process will be primarly merit-based, IMA has a special interest in EVD survivors.  In the case of Ebola survivors who are able to work, paid FHW employment has several potential benefits:

1) Access to good nutrition, psychological support, and treatment for residual effects, necessary for full recovery

2) The extra safety margin of apparent immunity to Ebola Zaire

3) Enhanced community acceptance due to status as a wage-earner and source of help for those who are ill

4) Any measure that increases acceptance of EVD survivors will indirectly promote the best possible solution for EVD orphans: adoption into Sierra Leone families.

In the face of potential exponential disease growth and a rapidly evolving public health crisis, we have five  priorities: 1) Courageous Patient Advocacy and Compassion 2) Safety 3) Speed 4) Simplicity 5) Sustainability.  We will be streamlining and expediting our operation by simplifying care guidelines, seeking the help of civilian organizations and local leaders, and when possible using existing structures and supply chains put in place by other NGOs, including Project Cure.  Our safety plan includes formal ETU training for our expat volunteers, formal, ongoing on-site education for our local staff, religious use of appropriate PPE, and adherence to WHO-recommended safety measures currently employed by MSF, PIH, and IMC.  

This is a unique situation that demands adaptability and flexibility.  We have no doubt that our current treatment model will have to be adjusted to fit realities on the ground.  Medical and moral decisions will be based on expert advice and consultation with our healthcare partners operating in West Africa.  The only thing that is not negotiable is our commitment to the safety of our personnel and the well-being of our patients, their families, and their communities.

Why Paramedics and not just MDs and RNs?

After spending 1-2 years in school, US Paramedics make field diagnoses and treat patients with only remote supervision of a doctor, providing advanced interventions such as IOs, intubation, nasogastric tubes, chest decompression, emergency tracheostomies, cardioversion, and cardiac pacing.  They also give several dozen medications in the US, including adenosine, diltiazem, metoprolol, morphine, versed, RSI cocktails, and much more.  Paramedics are accustomed to working in hazardous, high-stress environments, with minimal support, and are often faced with the need to improvise.  They are trained in the use of HazMat PPE.  They are committed to the safety of their crews, but also to rapid, effective response using the materials immediately available.  Paramedics often treat patients for hours or, in the case of rescues, days, before they reach a hospital         

On the use of survivors as patient care technicians:

Working in an Ebola treatment facility is a hot, physically tiring, and emotionally exhausting job.  Western-style infrastructure is lacking and in many current facilities proper PPE is not always guaranteed.  Even in facilities where the most stringent of safety precautions are used, mistakes inevitably occur and lead to exposures of staff.

When a staff member is infected, it has a negative emotional impact on other staff members, as well as potential recruits for the organization.  It prompts NGOs to pull out of Ebola-affected areas, and dissuades new NGOs from taking their place.  It creates expensive medevacs and fosters unease in the countries and communities to which infected staff return.

Several pieces of scientific literature (see Links) suggest that those who have recover from Ebola achieve persistent immunity against the strain with which they were infected  (The West African epidemic is caused by the Zaire strain).  There is even evidence that some individuals may be exposed and acquire immunity without ever becoming symptomatic.  More than one expat health worker has been very public about their belief that they are now at least relatively immune to the disease. 

According to WHO, Ebola has infected 10,000 - 20,000 people, and killed 70% of them.  That means that there are 3,000 - 6,000 Ebola survivors.  It is reasonable to assume that most of them continue to inhabit the homes and villages in which they were exposed.  After recovering, many provide care for family and neighbors infected with Ebola.  Not a single survivor has reported being re-infected with Ebola.

As IMA understands it, the current recommendation is that survivors work in the same level of PPE as regular providers.  Any change in this standard should properly be the result of very serious consideration by medical experts and an interagency ethics committee.  In the course of the West African epidemic, several measures have been approved emergently, measures which have not gone through the usual period of pre-approval testing.  As with ZMapp and Ebola vaccines, the decision of whether to change survivor PPE standards would be the result of a risk-benefit analysis.  It is possible that the natural epidemiological course of the epidemic has already created a far more thorough study of survivor immunity than could ever be achieved artificially.

At present, IMA feels that there is enough evidence of immunity to justify preferentially employing survivors as medical technicians.  So long as only those who have demonstrably survived Ebola and have recovered sufficiently to withstand the rigours of working in fully encapsulating equipment are used, we feel this adds an extra layer of protection to our operation.  For a high-profile example of an Ebola survivor who has returned to medical work, see British nurse William Pooley. 

In the hypothetical event that WHO and the Ministry of Health determined that survivors could safely work in Basic Precautions (in this instance gloves, boots, an apron, face shield, and a surgeon's mask would be an example), the game plan would be drastically changed.  Survivors have weakened immune systems and need to be protected from diseases such as respiratory infections, but PPE for this purpose is far simpler and less expensive than that currently used against Ebola.  Funds now spent on vast quantities of specialty PPE could be used on more medications and more medical facilities.  Time spent with patients would increase and physical stress on technicians would be reduced.  Interventions such as IV rehydration which are now often withheld due to safety concerns could be given with much less risk to both patient and caregiver, resulting in better outcomes.  Seeing human faces rather than plastic hoods would make clinics less frightening places for patients and families.  Less fear and higher survival rates would hopefully attract more patients earlier to treatment facilities, thereby reducing transmission in the community.

Visions of a seemingly vast pool of potential survivor technicians must be tempered by the realization that the bulk of current survivors are newly recovered.   Ebola is often a devastating disease with a long convalescent period, during which survivors tend to have weakened immune systems, are prone to infections such as pneumonia, and thus staff would need to be supported with antibiotics, etc. if they took ill.   Additionally, evidence is emerging of "Post-Ebola Syndrome" - a cluster of symptoms that includes visual impairment, aches, and fatigue.  Survivors have also just been through a frightening ordeal.  They may have lost loved ones and livelihoods, and be shunned in their communities.  Personal disaster affects different people in different ways.  To some it becomes a source of inspiration.  It is only a minority of survivors who are physically strong enough and psychologically willing and able to work as patient care technicians.  These are the people we will seek to employ.  As the epidemic goes on, the number of such people is one of the few resources that will increase.