At the CIM, we think a lot about “the good doctor,” and the qualities that distinguish an excellent physician. We respect perceptive diagnostic skills; we also value compassion, empathy, and caring. We don’t talk much about courage, mainly because it doesn’t often come up on the physician side. It’s different for our patients; they know all about the courage, grit, and faith it takes to keep going through pain, fear, uncertainty and difficult treatment. But courage for doctors? And grit, and faith?
Sometimes courage is just showing up. It’s dragging yourself out of bed in the morning after a terrible sleep that was mostly nightmares, and going to see who died in the night. It’s taking care of people with an infectious disease you thought you understood, and wondering if you – like your colleagues – are going to get it, too, despite your meticulous precautions. It’s lying to your worried family back home, telling them everything is fine, wishing you believed it. It’s trying to connect with patients when you feel physically separated by suffocating protective gear that muffles your voice and blocks most of your face, that weighs you down and saps your strength, when you can’t get the smell of decontaminating chlorine bleach out of your nose or the pictures of the dying out of your head.
Courage, says Linda Meta Mobula, M.D., M.P.H., who earned her M.P.H. at Hopkins, did her residency in medicine at Johns Hopkins Bayview, and did a post-doc fellowship in general internal medicine at Hopkins, “is not the absence of fear,” – she thinks about this quote a lot, from author Ambrose Hollingworth Redmoon – “but rather the judgment that something else is more important than fear.”
Last summer, Mobula felt that fear for two solid weeks as a physician at the Ebola Case Management Center of the Eternal Love Winning Africa (ELWA) hospital in Monrovia, Liberia. Mobula, who works for the United States Agency for International Development-HIV/AIDS and is a Science and Technology Policy Fellow with the American Association for the Advancement of Science, was asked to help by the Disaster Assistance Response Team of Samaritan’s Purse, a medical missionary group. She had practiced medicine in tough situations before, starting at Hopkins, where working in the ICU taught her “how to deal with critical patients and emergencies,” she says. “That has helped me with all the disasters I’ve responded to, but I don’t think any amount of preparation helped with this. We were all overwhelmed.”
An expert on providing health care in crisis, Mobula has worked in medical hotspots throughout the world. But nothing, she says, prepared her enough. The center had just expanded from six beds to 12. “As soon as I got there, everything went downhill,” Mobula says. “We were told that 10 more patients were coming.” The plan was to move to another location within the compound, put up tents, set up beds, and create an isolation unit. But local residents were protesting outside the compound, shouting and chanting. “They were basically threatening to burn the clinic down, because they thought we were bringing Ebola into the community,” she says. “They also thought that we were experimenting on people. Because of that, we decided it wasn’t safe to expand our clinic.” Many of the protesters had been child soldiers during Liberia’s civil war, and the situation threatened to turn violent.
Mobula was working with Liberian colleagues as well as doctors and nurses from Samaritan’s Purse, Médecins Sans Frontières (MSF, better known in America as Doctors Without Borders), and Serving in Mission. MSF “were overwhelmed in Sierra Leone and Guinea, and they did not feel that they had the capacity to open up a center in Liberia,” she explains, but “they had a physician and wash technical advisor come assist us in setting up the clinic, and I’m so glad they were there, because MSF are the world’s experts on Ebola.” The CDC was there, too, providing epidemiological support, helping track down contacts of those who had become infected.
That first evening, “we found out that one of our coworkers had contracted Ebola. As a result, a lot of the health care workers stopped coming to clinic, because of fear.” The doctor with Ebola was Kent Brantley. The next day another co-worker, Nancy Writebol, became sick. “That created even more fear,” Mobula says.
It was especially unnerving because no one knew how Brantly and Writebol had become infected. “They were extremely meticulous in donning and removing protective equipment,” Mobula says. “We all became extremely fearful.” She started having nightmares. “My nightmares would consist of me vomiting. I would wake up in the middle of the night and check my temperature. Wake up, check my temperature again.” For a couple of days, “we told our families everything was fine, don’t worry.” But it wasn’t fine.
Mobula took care of Brantly. “I hadn’t met him before he got sick,” she says. Months later, she had dinner with Brantly and his wife in Washington, D.C. “He had no idea what I looked like. He said, ‘I could only see your eyes.’ It was so emotional, such a wonderful reunion.” In addition to receiving the experimental drug zMapp, Brantly received a blood transfusion from an Ebola survivor he had treated in Liberia. Later, Brantly donated his own blood to U.S. journalist Ashoka Mukpo, physician Richard Sacra, and nurse Nina Pham; all have since recovered.
One-third of the patients were health care workers. After a devastating civil war, Liberia’s health infrastructure was already “extremely fragile,” Mobula notes. “When you add an Ebola outbreak, which they had never experienced before, that weakened the infrastructure even more. There is only one physician for every 100,000 people in Liberia. Unfortunately, a lot of Liberian physicians have passed away.”
The clinic’s personnel shortage took its toll. “Two of our colleagues were sick, and we had to isolate everyone who had been in contact with them,” says Mobula. ELWA staff met with the CDC, MSF and the USAID missions, and “we basically told them we couldn’t go on unless we had more support.” At the time, Mobula says, she felt that she was failing the patients. “I felt guilty, because I thought, we have to do everything we can, but we just realized it was impossible,” and the disease was spiraling out of control. At that point, Liberia’s president declared a national emergency, and the Ministry of Health and MSF took over and added a second clinic. “Unfortunately, I heard that as soon as it opened, it filled within a day, and patients were either turned away or they died at the door.”
Despite the fatigue and fear, Mobula worried about her ability to provide compassionate care, hidden as she was beneath layers of personal protective equipment. She could do little to show empathy except for “nodding or looking into the eyes of my patients with concern. We were advised not to touch our patients more than required for administering treatments, even while wearing full protective gear. I often wondered if these communication barriers caused them additional distress.”
What helped her and her colleagues keep going was “faith in God and prayer,” Mobula says. One New Testament verse kept going through her mind: “My power is made perfect in weakness,” written when the Apostle Paul was dealing with his own illness: “If it weren’t for the fact that we supported each other, it would have been very difficult to make it through. It really was a nightmare.”
Note: At press time, Mobula had returned to Guinea to help with the Ebola outbreak there. Mobula notes that her views and opinions are her own and do not represent those of the USAID.