Q&A: PIH Doctors, Ebola Fighters Share Cross-Atlantic COVID-19 Experiences

Nearly six years ago, the paths of Dr. Marta Lado and Dr. Regan Marsh crossed in Sierra Leone, during the height of history’s worst Ebola epidemic. Like many clinicians working together on the frontlines of a medical emergency, they began a lifelong friendship and collaboration. Their shared experience fighting a deadly virus, at the time largely unknown, was formative professionally, too—not least of all because it prepared them for the current fight against the novel coronavirus.

Since April, Lado, chief medical officer for PIH in Sierra Leone and an infectious disease doctor, has been working at 34 Military Hospital in Freetown, the epicenter of the country’s COVID-19 outbreak. So far, Sierra Leone has recorded more than 2,000 positive cases, with a 3.4 percent mortality rate. Not typically a PIH-supported facility, 34 Military Hospital’s infectious disease unit has been serving as the main referral hospital for the country’s most severe COVID-19 cases, with Lado at the helm of patient care in the isolation ward.

Marsh, an emergency physician, has been treating COVID-19 patients at Brigham and Women’s Hospital in Boston, a teaching affiliate of Harvard Medical School and one of the top hospitals in the world. Marsh also serves as PIH’s director of clinical systems, after having worked with the organization in Malawi and Haiti and preceding Lado as the chief medical officer in Sierra Leone.

Massachusetts, whose population is comparable to Sierra Leone’s, is now among the best U.S. states when it comes to controlling COVID-19. However, Massachusetts was at the center of the epidemic in the spring and has surpassed 129,000 cases overall, with a mortality rate greater than 7 percent.

Across an ocean—between one of the most clinically rich corners of the world and one of the most medically impoverished—Marsh and Lado spoke about their respective hospitals’ COVID response, their experiences treating a new virus, comparisons with the fight against Ebola, and how medicine and social justice are as tightly intertwined as ever.

How have the last several months been for each of you and the hospitals you’ve been working in?

Lado: The first two, three months were tough. We had very limited human resources. When the first cases came in the beginning of April, it was only one other physician and myself who were here, covering 24 hours, splitting day and night shifts for 30 beds of critical COVID cases.

We had a decent ratio of nurses, though not so many cleaners and lab technicians. Everybody was just giving 300 percent.

Marsh: The emergency department (ED) where I work in Boston has 120 physicians, including faculty and residents. That is probably more physicians than there are in  Sierra Leone. There are 3,500 nurses at my hospital; there are around 1,000 nurses in Sierra Leone. Several years ago, when our director of operations for PIH-Sierra Leone visited Boston, I showed him around our ED and he said, "There are more monitors and ventilators in this ER than there are in all of Sierra Leone." He was not wrong.

Those are the areas where the U.S. response was really fortunate. With strong leadership from the hospital, we’ve been able to rapidly scale up multiple ICUs and inpatient COVID wards.

And then on the staffing side, whole services were diverted to COVID. Clinicians from surgical and inpatient services that were shut down were redeployed to the ED, testing centers, or the respiratory infection clinics.

Lado: We were super lucky because we got three junior medical officers that volunteered to work with us in June, after two exhausting months of frenetic work. We are getting more resources like pulse oximeters, blood pressure machines, glucometers, oxygen concentrators, medications, etc. We now have two CPAP machines and three cardiac monitors, so we can monitor the most severe patients as an intensive care unit. And we are more experienced now; we’re all learning about the management of COVID-19, so things are improving.

Marsh: As Marta is saying, I think our care ultimately has gotten a lot better too—streamlined, efficient, compassionate. We didn’t have quite the resource constraints, obviously, but at the beginning of the epidemic, there was so much understandable fear about nosocomial transmission, because we had seen, particularly from Europe, how many physicians and nurses were getting infected.

For those of us who had spent time in West Africa, it was a little easier. Back in Ebola, right at the beginning of that outbreak—Marta will remember this—people talked about “no-touch nursing,” because if you touch the patient, you might get Ebola. The beginning of COVID in U.S. was not that bad, but there was such concern about health care worker infections, especially with PPE shortages, we had to think about its impact on our standards of care. But learning from Europe and Southeast Asia, and then seeing it ourselves, people became much more comfortable with the disease.

Lado: Arrogance, in this kind of a scenario, is not acceptable, because nobody knows what is best.

It's a moment that you are like a sponge, trying to absorb as much as you can from everyone and everywhere. Because there was no literature, there was no scientific evidence published yet; so we all needed to create the evidence ourselves.

Probably for Regan and I, this was a little bit less difficult, because we have lived in this context before: We didn't know much about Ebola, and we had to open our eyes and say, "Okay, let's work, adapt and learn."

I think that this outbreak is teaching the medical community worldwide that there's still a lot of medicine that we don't know, a lot of medicine that is not evidence-based, and we need to continue learning.

Was Sierra Leone better prepared for COVID-19 because of Ebola, and in a position to offer lessons to the U.S. and other well-resourced countries?

Lado: After the outbreak of Ebola, 34 Military Hospital had built this permanent infectious disease (ID) unit designed for potential outbreaks. So we were able to start from something very strong: a properly designed ID unit, with a well-differentiated flow of red zone and green zones, and a level-three biosafety lab and radiology department inside of the red zone. That made everything easy to start accepting the first patients with COVID and then setting up the first and only ICU for COVID 19 cases in the country.

Marsh: Marta, correct me if I'm wrong, but all health care providers in West Africa were trained so much on infection prevention control and personal protective equipment (PPE) that it was really easy to, I imagine, re-train people around COVID.

In the U.S., hospitals were rapidly trying to figure out: Do we need to wear masks all the time, or only in patients’ rooms? What type of masks are needed? How do I provide compassionate care and connect with patients while I'm wearing PPE? What's the concept of unidirectional flow for infection control? How do we convert regular floors into ICU floors? It was interesting because we were really building those systems rapidly as the epidemic unfolded here in Massachusetts.

Just before all of this, I was in Liberia in February, and hand-washing stations had popped up everywhere, just like during Ebola. The buckets came out of nowhere again. We have Purell everywhere in the hospital, but the concept of community-based hygiene is where there is real strength in West Africa, based on the previous experience of Ebola.

Testing has, for reasons of poverty or politics, proven difficult in both Sierra Leone and the U.S. How has that aspect of the pandemic evolved?

Lado: At the beginning of the outbreak, we were focused on contact tracing for people who were coming from abroad. Most of them were asymptomatic people, who were completely okay.

But as the outbreak moved forward, the moment we moved testing from just contact and epidemiological links of clusters to people who come to the hospital with difficulty breathing, or everyone with a fever—that is when we started realizing there was huge unnoticed community transmission. People didn't know where they got it from. It's everywhere.

We have been shifting to what has been happening in Europe, in the U.S., and many other places. If you have any symptoms, we will test you. Now my hope is that we can close the band of differences in social and economic status and start identifying and diagnosing people with COVID who are living in the poorest slums in Freetown.

Marsh: In Boston, the first people detected were largely from a biotech conference of, truthfully, mostly wealthy, white people from the suburbs. Most of them were healthy, but got early access to testing at a time that it was really hard. This is the same as Marta's talking about: We were testing people based on this perceived travel risk factor.

Then we started testing higher-risk people. Now we test everyone who's being admitted. And even if you’re not admitted, if you have any symptoms that could possibly be COVID, we test you.

Despite the fact that it has affected everyone, COVID-19 is not the great equalizer. Rather, it is reflecting back at us cruel injustices within our own communities and countries. How have you each observed this as doctors?

Lado: COVID has shown a big breach in society. At 34 Military Hospital’s COVID treatment center, 90 percent of our patients are upper middle- to high-class. Who are the people who get tested? Who are the people who have money to go to health facilities when they get sick?

These are the people who go to foreign countries for their medical checkups normally. They go to the U.K., the U.S., India, even Ghana and other places with better health facilities. They would never step a foot in a Sierra Leonean health care facility in their normal lives.

But then they could not leave the country because airports closed. There’s no other option. I think that these specific parts of society are rediscovering their own country and its challenges. It's exposing people who have been blind and in denial, who didn't want to see the reality of health care in their country.

Marsh: In the U.S., we can see now how COVID has had a horrible effect on poor communities and communities of color.

A lot of this has to do with structural racism in health care, and structural violence and economic injustices in our community that have existed for decades. Longer.

I also work at a community hospital with a strong Latinx community. We’d converted one part of the emergency department entirely to a COVID unit, with six beds. On many shifts, all the beds would be filled with Latinx patients and other patients of color, all with COVID, all with essentially identical symptoms and histories.

Many of my residents in the emergency department have written about their experiences having to intubate, or put in the ICU, immigrants and person after person of color.

In Boston and across the U.S., COVID has deeply magnified the health inequities we all see. It's been devastating in its impact on the populations that PIH serves.

What challenges do you still face?

Marsh: Massachusetts has done a really good job of social distancing, contact tracing, testing, and isolation and quarantine. It'll be interesting to see what evolves through the fall as people are, truthfully, a little tired.

Lado: We’re still very resource-limited. During Ebola, we had the same frustrations, but we had a lot of foreign aid.

Sierra Leone doesn’t have any intensive care department. And the training in intensive care and critical patients is very, very low. These opportunities should teach us that we need to strengthen medical education and clinical training. We are seeing that people are dying because of many reasons, but one of them is that there is not much experience among the health care workers in critical care.

Marsh: Marta is a hero in all of this, to have taken her Ebola lessons and now be applying them to lead the COVID response. It's really incredible, and we're fortunate to have her.

Lado: Oh, don’t say that. You would do the same if you were here! And the truth is that you already did the same while you were here during the Ebola outbreak. We need to continue supporting our communities.