There and back again

HOLDEN, Mass.—Dr. Rick Sacra was at his Massachusetts home only a few weeks out of the hospital, showing no signs of feebleness. He had survived Ebola in September, but the virus weakened his immune system. In October he went back to the emergency room with a cough and fever. Sacra, 52, is an SIM missionary who contracted Ebola in August while delivering babies in Monrovia, the capital of Liberia. Struggling to return to normal health, Sacra learned he also has Lyme disease—but he’s shrugging it off as a common New England affliction.

Liberia is what’s on Sacra’s mind. “Are we going to talk about Africa?” Sacra asked after patiently explaining his own health over scones and coffee. He is already back to work against Ebola. The day after we spoke, he planned to petition a local hospital to donate surgical instruments for ELWA, SIM’s longtime hospital in Monrovia that’s become a principle treatment center for the city of 1 million. He has been speaking and raising money for SIM. He has stayed in touch with another SIM missionary doctor at the hospital—who told Sacra the situation had not improved since August.

Sacra, his wife Debbie, and their three sons lived in Monrovia for 15 years—surviving civil war, Charles Taylor (Liberia’s brutal president, the only head of state convicted of war crimes since Nuremberg), HIV/AIDS, and now Ebola. Sacra was a physician at SIM’s ELWA Hospital—short for Eternal Love Winning Africa and established by SIM missionaries in the 1950s—taking on various roles as needed from the hospital’s director to the country’s director. Debbie was a teacher at the ELWA school, all on the same campus. In 2010 they moved back to Massachusetts and now Sacra divides his time, spending about four weeks a quarter in Liberia and scavenging resources for the hospital when he’s back in the States. He went to ELWA in August to relieve overwhelmed staff and work with pregnant women, a basic healthcare service that had disappeared in Liberia as all resources turned to Ebola.

Sacra realized he was sick early at ELWA, and healthcare colleagues quickly evacuated him on an expensive but uncomfortable flight, strapped to a gurney with his feet dangling over the end. He estimated that his flight back to the United States cost $200,000, which the U.S. State Department arranged and insurance covered.

“They have not canceled our medical evacuation insurance yet,” George Salloum, a vice president at SIM and the team leader for the Ebola response, said cheerfully.

Sacra battled through Ebola’s vomiting and diarrhea at the Nebraska Medical Center, one of three hospitals in the United States that already had biocontainment units and trained containment staff. When Sacra described his illness, he said, “It really wasn’t that bad,” even though he was so sick he hardly remembers the worst parts. As his health improved, he told the staff at the Nebraska hospital stories about Liberia.

Liberia was familiar with devastation before Ebola, and ELWA has been present for much of that devastation. Thanks to the foresight that comes from long experience on the ground, ELWA had the first Ebola containment center in Monrovia, and its campus became the hub for Liberia’s fight against the disease.

As the epidemic began to rage late this summer, Doctors Without Borders (also known as Médecins Sans Frontières, or MSF) set up an Ebola hospital on ELWA’s campus. Without ELWA’s existing infrastructure, MSF would have had to run makeshift facilities off a generator and dig wells. An SIM doctor now oversees a separate Ebola ward of about 100 beds, staffed by the Liberian Ministry of Health, with whom SIM has had “a good relationship for years and years,” said Salloum. Then the U.S. Centers for Disease Control and Prevention moved in on SIM campus too, setting up a lab for Ebola testing there.

Now ELWA’s campus has about half the beds for Ebola in the country, according to SIM, between MSF’s hospital and the ELWA ward, all on the ELWA campus. USAID plans to vastly expand the number of beds for Ebola in Liberia soon, but ELWA was the first line of defense. Sacra credits the Liberians with keeping the ministry alive over the decades, and SIM has prioritized local control of the mission. Today the mission hospital is almost completely staffed with locals: 125 Liberians, and, right now, two Americans.

Because the staff members are local, they understand the culture and have relationships in the community. The Liberian staff holds daily prayer and devotions with patients, and in some situations Ebola patients have led devotions themselves. SIM is affiliated with a local denomination called the Evangelical Church of Liberia, which has trained all of its pastors in educating their congregations about the virus. When MSF first started building its hospital on ELWA’s campus, some youth came by and started throwing stones. SIM held meetings with local leaders to diffuse the unrest, and other NGOs faced more violent reactions from communities who have suspected the Western groups of bringing the virus rather than treating it. “You’re a known quantity,” said Sacra.

The mission first started in 1952 as a radio station to transmit the gospel, a ministry that continues, and shortly thereafter grew to include a hospital, school, and church planting operation. Civil war broke out in 1990, with the brutal Charles Taylor rising to power. Three refugee families arrived at ELWA’s campus in May 1990, and by July the 137-acre campus was hosting 22,000 refugees. “There were people from every tribal group and every walk of life,” recounted Bill Ardill, a surgeon and the hospital administrator at ELWA, in a 1990 SIM newsletter. “There was even one segment who drove up in Mercedes Benz cars and asking if we took reservations. But most were average citizens forced from their homes by the gruesome violence.”

The hospital was treating those wounded in the fighting from both sides. MSF, in a foreshadowing of the partnership with SIM on Ebola, brought in thousands of pounds of rice to feed the refugees on the campus. The radio station transmitted news about the war, although Taylor at one point forced ELWA missionaries at gunpoint to let him use the radio transmitter to broadcast that he was the new president.

Fighting between the rebels and the government soon broke out on the campus, and the missionaries arranged evacuation for the refugees and hospital patients. ELWA’s campus was shelled after they were forced to leave.

ELWA reopened the following year. The Sacras moved to Monrovia in 1995, when the hospital was still treating gunshot wounds. Throughout the ’90s, warring factions forced SIM missionaries out of the country, but they always came back. The hospital was again looted and destroyed in 1996, just after SIM had rebuilt its radio transmitter. The Sacras had to evacuate.

“There was a point at which SIM didn’t think we were going to go back ever,” said Debbie. But the Sacras successfully lobbied SIM to let them return to Liberia in 1998, even though violence and warfare remained widespread. The SIM missionaries returned to find the Liberian staff fixing the campus and having reopened the clinic.

After the subsequent years of disease and violence, the Liberian staff and SIM missionaries in many ways were ready for Ebola. In April, anticipating the virus, ELWA converted its chapel to a containment unit with six hospital beds, the only such unit in Monrovia at the time. “There wasn’t money,” Sacra explained simply. In June, Ebola patients started coming to ELWA, and the staff squeezed eight beds into the containment unit.

The virus arrived at an inconvenient time for the hospital. Samaritan’s Purse, which has partnered with SIM against Ebola, had been working on rebuilding the 60-year-old hospital when the crisis hit and construction had to stop. ELWA functioned with what few resources it had. The staff worked with handmade personal protective equipment (PPE), because industrial gear wasn’t available to buy in Liberia. Now the hospital has imported PPE.

Samaritan’s Purse, with its experience as a relief organization, has helped with establishing a supply chain for ELWA in the crisis, a critical component when basic equipment isn’t available in-country. Samaritan’s Purse recently chartered a Boeing 747 to deliver supplies into Liberia and gave some of the cargo space to SIM.

Without ELWA, “the whole response would have been another month behind,” said Debbie. “At least there was something there.”

In July SIM and Samaritan’s Purse converted the kitchen and laundry room to another containment unit, expanding their capacity to 20 beds. Hospitals were sending Ebola patients to ELWA because every time an Ebola patient arrived at one of the other hospitals, they would have to shut down to decontaminate everything, leaving other critical patients in crisis. Hospitals didn’t know “who was coming with or without Ebola,” said Salloum. SIM redesigned its hospital to have only one entrance point, so staff could do triage and separate Ebola patients from regular patients.

In those initial months, many of the Ebola patients arrived at the hospital when it was too late, as most people didn’t believe Ebola was real. When Dr. Kent Brantly, an American doctor with Samaritan’s Purse who came to work at ELWA, contracted the virus, the Ebola ward at ELWA had seen only one survivor. By August, patients started coming earlier in their illness and survival rates went up. But the doctors say they are still in the throes of the epidemic.

For the Sacras, the ripple effects of the disease are devastating, having watched the country just start to recover from the civil war. The economy has halted and all schools are closed, including the school on ELWA’s campus. Basic healthcare has fallen apart. ELWA is one of the only hospitals in the country that will admit pregnant women with a fever. When an Ebola case walks in, some hospitals close for three weeks to make sure none of the staff have the virus. A Catholic hospital in Monrovia had to shut down after losing several staff to Ebola; it hopes to reopen this month.

“I think this is going to have just as big of an impact [as the civil war],” said Sacra. “When the Ebola epidemic is over there’s going to be a rebuilding of institutions.”

The Sacras have lost close colleagues, too. Dr. John Taban Dada, a Ugandan who became a naturalized Liberian, died of Ebola in early October. Dada was a surgeon and medical director at ELWA for about five years before going on to work for the Liberian Ministry of Health. He died at ELWA, the hospital where he became a Christian, according to Debbie: “He was much loved.”

Because Sacra survived the virus, he is now immune to it, and he has taken that as a sign. The patient wants to return to being a doctor. Sacra plans to travel back to the hospital in Monrovia in January, the soonest he can go.

Viral march

Dec. 28, 2013: Emile, age 2, dies of unidentified hemorrhagic fever in Guinea, followed by his mother, sister, and grandmother.

March 22, 2014: Health officials confirm Emile’s death from Ebola, and a death toll of 59.

March 28: With two cases reported in Liberia, ELWA Hospital, working with SIM and Samaritan’s Purse, opens the first Ebola containment and treatment center in Liberia.

May 26: Ebola reaches Sierra Leone.

July 23: U.S. physician Kent Brantly falls ill with Ebola, and becomes the first Ebola patient transferred to U.S. soil. He recovers with use of experimental drugs.

July 25: Liberian government worker Patrick Sawyer dies in Nigeria of Ebola, and two days later Liberia closes border crossings.

Aug. 8: WHO declares Ebola an “international health emergency,” with a death toll exceeding 1,000.

Oct. 7: A Spanish nurse becomes the first person to contract Ebola outside West Africa.

Nov. 20: Mali reports six cases of Ebola with five deaths, bringing the total reported cases to 15,145 (over 7,000 in Liberia) with 5,420 deaths.