Ebola: An epidemiologist’s experience in Sierra Leone

Epidemiologist in Sierra Leone

Most of us have seen the news and understand the devastation that has come from the Ebola outbreak in West Africa. But, one of Ashford University’s faculty members, Avi Stein, has actually seen and experienced the disease first-hand.

Lieutenant Commander Avi Stein, an associate faculty in the College of Health, Human Services, and Science, was on a two-month assignment in Sierra Leone, one of the countries hit the hardest by the Ebola virus. As an epidemiologist, a public health professional who investigates patterns and causes of disease and injury in humans, with the Centers for Disease Control and Prevention (CDC), he was sent to help with the investigation of the epidemic and help stop its spread.

“It was an interesting trip,” he remarked. “Sierra Leone truly is a third-world country. For example, they don’t know what an oven is since they cook on open fires. It’s a very different culture.” He mentioned that Ebola is not foreign to the African continent itself, but the widespread epidemic is truly a new phenomenon.

Sierra Leone, with a population of about 6 million people, is comprised mostly of districts and its capital, Freetown, a small city located on the western coast of the Atlantic Ocean. The country is also bordered by Guinea to its north and east and Liberia to its south.

Commander Stein reported that epidemiological methods discovered the country became infected with Ebola through the border District of Kailahun. “We believe that people traveled across the border from Guinea” unknowingly infected with the virus which then quickly spread through the town. “You can then follow the line of infections from there to Kenema and right up the main road to Freetown.”

By looking at the numbers of reported cases, epidemiologists are able to determine the highest concentrations and how the virus traveled from town to town. “There are so many hidden cases out there,” he remarked, explaining that hidden cases are usually unreported initially until teams are dispatched for one death and discover many more bodies.

“One of my team members went out with one of the burial teams and found numerous hidden cases,” Commander Stein said. “It was emotionally stressful and a bad experience for her,” he remarked, noting that there were apparently many dead village members who had succumbed to Ebola yet were left unreported.

“That’s why this is so hard to pin down and stop,” he explained. Too many people have died and were given a traditional burial – which actually promotes the spread of Ebola. “Someone would report only one case, so you go out to institute a safe medical burial but then find far more dead bodies,” Commander Stein further described the situation. “It’s actually heart-breaking.”

The traditional burial in the Western African culture is very different than in America. “Here, we fear dead bodies. But, in Sierra Leone, it is just the opposite. When someone dies, the family and village members wash the body and hold a public funeral. Everyone is expected to hug and kiss the body as the person’s soul crosses over.” Unfortunately, that ritual has killed so many more people since Ebola entered the nation and continues to spread at an alarming rate.

In order to stop the spread in this manner, the country has instituted safe medical burials for the Sierra Leone residents. It is a modification of their traditional ritual minus the touching. This adjustment allows the individual to have a respectful death and cross over while maintaining health among those left behind.

Since Ebola has struck, the nation has implemented a “no touch” policy – fully upheld in the capital and now trickling out to the districts. “Things are very different,” Commander Stein said. “One of the weirdest things to experience is a ‘no touch’ country…no hugs, no high-fives, no handshakes, nothing.” Unfortunately, it almost has to be this strict to halt the spread of Ebola.

Besides visiting the districts and small towns within those districts, Commander Stein was able to create a more stable surveillance and reporting system in the country. “I ended up becoming the National Data Manager,” he noted. “When I got there, the data on Ebola was scattered at best. People were not reporting regularly and often not at all. That’s why the discovery of tremendous numbers of hidden cases.”

Commander Stein utilized CDC resources, a program called Viral Hemorrhagic Fever (VHF) to establish a national database of all suspect, probable, and confirmed cases of Ebola. The task was monumental as VHF was initially designed to be used in a small outbreak. Commander Stein found a way to establish independent databases across the country and construct a system that allowed each database to send sync files to a national database. Prior to the implementation of VHF, the country reported their cases the old fashioned way; pen, paper, and a cell phone.

“They tried to do this in Liberia but with no luck,” Commander Stein commented. “We were pleased it worked in Sierra Leone.”

Just because they now have a solid national reporting system doesn’t mean the virus is under control. “It’s far from over,” Commander Stein said. “Ebola is still spreading, and Sierra Leone is nearly worse off than Liberia.”

According to the CDC, the outbreak hit the country in May 2014 with three other countries also experiencing outbreaks: Guinea, Mali, and Liberia. The CDC has reported that this outbreak is the largest and most complex in history. As a result, the CDC has issued a Level 3 warning on travel to that country, urging all US residents to avoid nonessential travel to the affected countries.

Commander Stein is among those “essential travelers” to the country. In fact, he returned on December 6, 2014 for another two months with a new charge: to become the first CDC Safety Officer in the country. “I will basically be working with our teams on safety and security, as well as mental health and resiliency issues.” It’s a tough environment to visit, let alone to spend a significant amount of your time. He is there to help keep sanity among the CDC and other health workers.

Every little cough and sneeze is taken seriously. Commander Stein remembers one specific incident that “scared the *cough*” out of him: he woke up in his Freetown hotel room with a fever, .one of the first signs of Ebola. He diligently recalled his encounters of the past few days and remembered meeting one of the American doctors who, at the time, simply looked tired but was later diagnosed with Ebola. “I was scared out of my mind.” Still, in those moments, he remembered his bigger concern was for his team. Three other staff members had been with him in the field as well. “I was really concerned that if I had it, so did they.”

He quarantined himself in his hotel room and waited it out. The fever broke within the same day, and thankfully, it turned out to simply be a head cold, which was being passed around the hotel at the time.

Never once did he question why he was there, not even during his fever day. “I’ve been in this situation before where I’ve asked myself, ‘What am I doing?’ and the answer is always the same. I question the impact that I’m having on others and not what this might do to me.”

Commander Stein is also a trained volunteer firefighter and paramedic, once a full-time career. “I’m not a stranger to risking my life.” He indicated that he has always been far more interested in making sure others are helped and safe.

Stein’s wife, Erica, his daughter, Dylan (6), and son, Devin (3), seem to take his work in stride. They communicate using Skype while he is away. “My wife knew about my life as a firefighter and paramedic going into our marriage,” Commander Stein noted. “This is no different and she understands.”

Dr. Nina M. Bell is the chair of the BA in Health Education degree program for Ashford University. She earned her PhD and MPH from Walden University and has been at Ashford since 2011. A version of this article first appeared in the Health Promotion Quarterly.

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