The World Health Organization (WHO) has declared the Ebola outbreak in West Africa a health emergency—a sobering reminder of the importance and sacrifice of frontline health workers. In affected countries, health workers not only provide the care needed for an Ebola victim to fight the deadly disease, they are a critical component of efforts to stop the outbreak from spreading further. Ebola-affected countries are among 83 countries worldwide that the WHO last year (2013) reported to have below the minimum ratio of health workers needed to provide basic health services to a population. Strategic investment in frontline health workers cannot be overstated as a key to lasting health in these countries.
Nurse-midwife Marion Subah, a native Liberian and Jhpiego’s senior technical advisor in Monrovia, has dedicated her adult life to providing care to the people who need it most. She spent much of the Liberian civil war nursing child victims, and since then, she has been part of the Rebuilding Basic Health Services (RBHS) Project, led by John Snow International, in collaboration with Liberia’s Ministry of Health and Social Welfare (MOHSW), and including partners Jhpiego, Johns Hopkins University Center for Communication Programs, and Management Sciences for Health. The project is funded by the U.S. Agency for International Development.
In recent weeks, Marion, as part of the RBHS team, has been working with frontline health workers to reinforce quality case management for Ebola patients with an emphasis on health worker protection and safety. We caught her for a quick phone conversation as she was enroute to a health facility.
What is your assignment at the health facility?
One of my major responsibilities, alongside RBHS colleagues and Liberia’s Ministry of Health, WHO and others, is to train health workers in case management, infection prevention, and behavior and social interventions using a program that has been adapted for the Ebola outbreak. RBHS has been supporting the MOHSW in capacity building and increasing access to quality health care since 2008. With the Ebola outbreak, RBHS has been supporting the Ministry of Health and providing infection prevention and control training. In addition, RBHS has provided support for infection prevention supplies and materials for behavior change communications, which is an important focus in managing the outbreak. My colleagues from RBHS, Jhpiego, the MOHSW and others and I have trained many health workers who have gone out to hundreds of facilities, in eight counties so far, to do more training themselves.
What skills and techniques do you focus on in these sessions?
We talk about Ebola: what it is, what to do at the health facilities with Ebola patients and how to prevent it from spreading. We talk a lot about behavior change, handwashing—which is very important—and infection prevention. We talk about using personal protective equipment and procedures to prevent contamination.
At the end of our training, we have a slide that says: “What will you do?” And we ask people to make a commitment about what they’re going to do in different situations, whether to advocate for handwashing or other control measures.
How many people have you reached?
Nearly 50 teams, headed by Dr. Rose Macauley of RBHS and Dr. Caullau Jebbeh Howe of the MOHSW. and others are reaching health workers in their facilities. Probably over 1,000 staff in health facilities, both professionals and nonprofessionals, have been reached with these updated skills sessions.
How are the health workers feeling?
We have so many health workers who have gotten infected. Of 63 health workers who were infected by August 5, 30 of them have died. So I said, “Well, how come health workers are still getting infected, after we have been teaching and letting them practice basic infection prevention techniques?”
And I started thinking this because of my experience during the war: sudden and mass death is too much for many people, especially the death of colleagues, and we need to stress psychosocial care for health workers.
We need to help the helpers.
So I decided we should ask health workers about their fears and acknowledge that what they’re feeling is normal, then talk about how to cope with it.
During one of these discussions, there was a health worker who talked about how afraid he was the first time he encountered a patient with Ebola. He didn’t want to have any physical contact with the patient, and he was so terrified. He was not alone: his coworkers and everyone I have talked to say that they don’t want to care for these patients, or they are depressed, or they cannot eat due to stress.
What helps them overcome their fears?
Well, we talk about our deepest fears, and then we say: “That is normal. You do not need to feel abnormal.” But we say that no one can stay this way forever, so how can we move to appropriate behavior?
What really helps is just empowering them to talk to each other. To ask each other: “How did you cope?” Our hope is that every day, health workers will talk with each other and help each other to provide safe care.
You’re a midwife, too. How has the Ebola outbreak impacted pregnant women and mothers in Liberia?
It’s a big issue. It’s a really big issue. Recently, I heard that 17 people—health workers and patients—were exposed to Ebola because a pregnant woman came in bleeding, and the health team thought that it was pregnancy-related; so they sent her to the maternity ward. But after being exposed to so much blood as they tried to understand what was happening, the health workers realized that maybe the woman had Ebola.
So many, many midwives and nurses are scared to be exposed, and mothers who need care are not receiving it. We hope that will get better and better.
You lived through Liberia’s civil war and provided substantial care for victims of the war. What did you learn then that you can apply to the present situation?
We need to build the capacity of the health workers, so that they can safely provide quality care, without fear of dying themselves. We need to get the isolation wards and Ebola treatment centers fully functional, and infection prevention practiced effectively with the appropriate resources so that our health workers can be effective in the care that they provide.