By Lee Chottiner
As Blanche Rybeck listened to news reports about the Ebola outbreak in West Africa last September, she knew she had to help, but not for the reasons you might think.
True, Rybeck, a 57-year-old oncology nurse at UPMC CancerCenter in Washington, Pa., thought going to West Africa was the right thing to do; she believed she was answering her government’s “call to duty” and she knew she had a particular skill set needed in Africa.
But Rybeck, an Ohio County resident, had another reason for going: to repay a debt.
She was named Blanche for her great-grandmother who, together with her husband, died in the Spanish Flu pandemic in 1919. Their deaths orphaned Rybeck’s grandmother.
In Africa, Ebola has turned many children into orphans.
“I know one of [my grandmother’s] college teachers and other people in New York City somehow stepped up and decided to pitch in and allow my grandmother to make it through that kind of trauma,” Rybeck explained. “Somebody helped her through that, so she became a huge part of my life, and a lot of other people’s lives. So I thought somewhere over in Sierra Leone is the next grandmother, and this was a way to return the favor.”
Rybeck, who just returned from Sierra Leone, a West African nation decimated by Ebola, spent five weeks there helping to set up a triage system in a government hospital in the country’s Kono District. She also helped native clinicians develop a charting system for the sick and cared for patients who Sierra Leonian doctors and nurses couldn’t—or sometimes wouldn’t—treat.
She returned to work at UPMC last week after a 21-day monitoring period at her Dallas Pike farm.
She’s not alone. According to the West Virginia Department of Health and Human Resources, 40 “return travelers” have been monitored for Ebola in the state. DHHR Communications Director Allison Adler said a traveler is defined as someone “who has travelled within 21 days from one of the countries with widespread Ebola transmission: Guinea, Liberia or Sierra Leone.”
She didn’t know how many of the travelers were medical professionals treating people in the stricken countries.
While Rybeck never came in contact with an Ebola patient herself, she saw firsthand how the outbreak had overwhelmed the country’s poorly equipped healthcare system, hindering efforts to treat patients with other illnesses and conditions the could be cured in less-dangerous times.
“You don’t want to expose a 3-year-old that’s coming in with malaria, but you have to test them to make sure it’s not Ebola, and you don’t want to expose them to someone else who might be dying of Ebola, and you don’t know,” Rybeck said. “In the time of Ebola, you have to treat everything like it might be Ebola.”
Rybeck’s desire to help others comes naturally. She is the daughter of Sivia and the late Dr. Arthur Rybeck of Wheeling, both longtime active members of Temple Shalom. Arthur Rybeck, a dentist, was well known for the free clinic he ran at his farm. He will be posthumously inducted into the Wheeling Hall of Fame on May 30.
Ebola, also known as Ebola hemorrhagic fever, is a rare and deadly disease that is spread through direct contact with infected persons, animals or their body fluids. It is named for the Ebola River in the Democratic Republic of the Congo where it was discovered in 1976.
The 2014 Ebola outbreak is the largest in history, according to the Centers for Disease Control and Prevention. Guinea, Liberia and Sierra Leone were the countries hardest hit by the disease. To date, the CDC reports about 14,000 laboratory-confirmed cases in those affected countries, resulting in more than 11,000 deaths. Elsewhere, 33 laboratory-confirmed cases combined have been reported in Nigeria, Senegal, Mali, Spain, the United Kingdom and the United States, resulting in 15 deaths.
In a hopeful development, the World Health Organization recently declared Liberia free of Ebola after no new cases were reported there in 42 days. Rybeck said the number of new Ebola cases in Sierra Leone is also trailing off. Clinicians at the hospital where she worked referred only four to eight cases a week to Ebola Treatment Units (ETUs) for testing, she noted, all of which came back negative.
“Kono District had not had an Ebola case the whole time I was there,” she said. “So I was never around someone with Ebola,” Rybeck said. “That’s the great news; it is possible to get to zero, and Sierra Leone is on its way to zero.”
Rybeck traveled to Sierra Leone with 11 other clinicians selected by Partners in Health, a Boston-based global health organization that brings modern, innovative medicine to countries in need through long-term partnerships with providers in those lands.
She didn’t just sign up, though. All volunteers go through a grueling vetting process that includes at least two separate interviews, and they must meet a series of exacting criteria.
“Some of it is health-related and some of it is, as funny as this sounds, size-related,” Rybeck said. For instance, “you have to be a certain size in order to fit into the protective equipment that they have available.”
“They [also] want to make sure you understand the conditions there,” she continued. “It’s pretty rustic. I grew up camping; I’m used to living simply.… I’m not going to be missing the TV; I don’t even have a TV.”
The PIH finally approved Rybeck’s application and selected her for “deployment” to Africa. Its use of military jargon, she said, was deliberate.
“It’s a U.S. government-led effort, and you were under protection of the U.S. Armed Services,” she said, “so if anything happens to you, you would be medevaced out to the nearest U.S. Army facility. At that point, there was still a U.S. Army presence in Liberia.”
After one week of training in Boston, and a second week in Freetown, the capital of Sierra Leone, Rybeck and her “cohorts” were sent to regional government hospitals around the country. The Kono District, where she was sent, is the heart of the country’s diamond-mining region and the scene of bloody fighting during Sierra Leone’s civil war from 1991-2002, which inspired the motion picture, Blood Diamond.
The hospital conditions were primitive. There was no running water, no sanitation facilities (patients were told to bring their own pots), and few trained physicians or nurses.
Many Sierra Leonians, she noted, turn to traditional healers before going to hospitals.
“The hospital is a last resort,” Rybeck wrote in one of her many emails home. “So today I helped assess a man who showed up after two months of trying to care for a wound to his foot at home. The man’s foot was completely necrotic. Dead, dried up, his foot looked mummified. Oh, I should mention, it smelled so putrid that he [and] another man with a similar wound, could not be kept with the other [patients].”
Lab work was basic at best. Most tests necessary to diagnose the conditions doctors saw weren’t even available. They ordered those that were by scribbling notes on scraps of paper and sending to the lab. The test results would be jotted on those same scraps and sent back to the wards. Frequently, those papers, and their much-needed findings, were lost.
Many nurses weren’t even nurses, but volunteers—people bravely doing whatever they could to help the sick in the wards. It wasn’t unusual, Rybeck said, to have a one “nurse” (her quotation marks) working a shift.
Patients had to buy, not only their bed, but also their chart, which usually consisted of a folder with little information beyond name and age. If a patient needed an antibiotic, the family had to buy the equipment then ask the nurse to administer it. If an IV was needed the family had to buy that, too, then find a nurse to put it in—no nurse, no antibiotic.
“Part of what became clear to me as a nurse there is that if you are a person in a hospital without a family, you’re totally abandoned there,” Rybeck said, “nobody’s going to take care of you.”
The dearth of trained doctors and nurses wasn’t surprising, Since Ebola is a disease spread by direct body contact, health care providers were among the first to contract it. Many of them died as a result.
She recalled one nurse, the matron of the staff, who always showed up for work wearing a starched white uniform and cap reminiscent of another time. At first, Rybeck wondered how she could leave younger, untrained nurses alone on the floor. The she gradually understood what her colleague had been through.
“It’s so foreign to her what’s happening now, and all her colleagues are dead,” Rybeck said. “She probably feels really alone and the fact she even shows up is pretty amazing. So any expectations I find myself falling into I have to remind myself that it’s easy for me to say, I’m just popping in for five weeks.”
Rybeck tried not to get too close to her patients.
“You have to concentrate on your job because people are dying everyday there,” she said. “And it’s not from Ebola. It’s from stuff that you’re sometimes not sure what it is, but sometimes you are and you know that they wouldn’t be dying at home in the United States, and there are other things going on that are really frustrating. You just have to keep your eye on your job—what can I do in each moment to be an advocate for that patient.”
Still, there were some patients she will never forget, like one woman who had epilepsy, which is a taboo in Sierra Leone.
“Nobody would take care of her,” Rybeck recalled. “At least twice I would find her out in a ditch, just laying out in the ground, unable to take care of herself or clean herself or feed herself. So because it’s not part of what the nurses there do to take care of someone like that, and as an American nurse I can’t walk by someone like that and not take care of them, I would get another American nurse and we would get her cleaned up and into a bed.”
Then there was the 15-year-old girl—an orphan—who came into the hospital with sickle cell anemia, a necrotic lesion in her humerus, the bone extending from the shoulder to the elbow. She also had an abscess that was producing discharge from the infected bone.
“She had no family; the Red Cross had found her in the bush, just hiding,” Rybeck said. “She didn’t speak much, probably because she probably knew mainly her tribal language and not English. There are no orthopedic surgeries done there and what she needed was orthopedic surgery. The only place she could get it was Freetown, but she was a minor, so there was no one to take her or pay for the operation.”
One day, Rybeck found the girl crying in her bed. She tried asking her in Krio, a regional language much like Pigeon English, if she was in pain, but she couldn’t get an answer.
“It took me two days to figure out that she wasn’t crying because she didn’t have pain medicine; she was crying because she had finished the antibiotics and she knew she had to be on the antibiotics until she got the surgery, but she had no one to get her the antibiotics.”
Once they knew that, nurses approached PIH to get the antibiotics. By the time Rybeck left the country, arrangements were made to send the girl to Freetown for the surgery and for someone to act as her legal guardian.
‘Models’ for healthcare
While in the Kono District, Rybeck met three PIH-hired translators—Alex, Fodei and Mariama—who helped the clinicians communicate with their patients. She became close to them.
“The three translators were actually two community health workers and a nurse; it was really great to be working with them,” Rybeck said. “They had been there, in fact, through the worst of everything, and I think [they] were happy to be translators instead of clinicians because what they had seen was so scary.
“When we first started there,” She continued, “Alex really didn’t want to touch any of the patients.… I think it was because he had seen just such horrific stuff, and until we could model what we thought was a good system to protect the nurses there, they were pretty much hands off.”
That changed by the end of her five weeks of duty in Sierra Leone.
“These were Sierra Leonians who had seen the trauma of Ebola, who had at one time been clinical staff, had then gotten a job with PIH as translators, but who obviously had clinical skills that were ready to grow—if you could make it safe enough for them to get back to practicing,” Rybeck said. “And that’s what I saw happen. And so, by the end of it, I said, ‘Wow! you guys are the future of nursing in Sierra Leone.’ ”
This is what Sierra Leone needs she said: “models” for a modern healthcare system can work kind the country.
There are a couple models in the country, she said. One of the better examples is the Wellbody Alliance medical complex near Koidu, the district capital of Kono, which developed a maternity ward where babies could be safely delivered by clinicians wearing protective gear. Pregnant women and their children were among the most vulnerable people during the Ebola crisis.
Rybeck pointed to little victories such as that girl, and the general spirit of the Sierra Leonians to bolster her belief that they will rebuild their country.
Many countries offered assistance during the emergency, including the United States, the United Kingdom and the Netherlands, which set a up a series of mobile ETUs around the country to test patients suspected of having contracted Ebola. African nations pitched in, too—most notably, Uganda, which has its own experience with Ebola outbreaks and sent physicians to Sierra Leone to train other clinicians.
But more must be done, Rybeck said, particularly by American healthcare systems.
“We cannot have our institutions call themselves world-class health organizations, and not step up to the plate when there’s a world health crisis,” she said. “If your government says the United States needs to be involved in stopping Ebola as part of a national security issue, then our tax-funded organizations—these are all tax-funded organizations— need to step up to the plate and be part of the solution.”