A CDC Epidemiologist Talks About Life on the Front Lines of the War Against Ebola

Dr. John Redd, a captain in the U.S. Public Health Service, was sent in September by the Centers for Disease Control and Prevention (CDC) to Sierra Leone, one of the three West African countries most devastated by the Ebola epidemic. The 52-year-old was assigned to Makeni, the capital of the northern district of Bombali (pop. 434,000). After six weeks battling the deadly disease, Redd returned to his home in Santa Fe, N.M., where he described his experience to Time Inc. senior editorial adviser Richard B. Stolley.

THE ROLE OF CDC DOCTORS DEPLOYED TO FIGHT EBOLA IS NOT PATIENT CARE. WHY?

I am a medical epidemiologist, and epidemiologists control disease at a population level. I volunteered to go to Sierra Leone with CDC to help control the outbreak and support local efforts to slow it down.

WASN’T IT DIFFICULT FOR YOU NOT TO TREAT PATIENTS?

I was treating patients, but not one at a time. That’s public health. I was supporting the system of outbreak control so that there will ultimately be fewer patients to treat.

WHAT WAS YOUR GOAL?

To slow down the spread and reduce transmission, because that’s what really controls an outbreak like Ebola. It’s the public health measures that will end the outbreak, not treatment, as important as treatment is.

HOW DID YOU PROCEED?

First is case identification or case finding. That means helping local authorities find people in the community as early as possible who have the disease or may have it, moving them into holding centers so they are removed from their community while their labs are pending, and then sending patients who are positive to an ETU, Ebola Treatment Unit. That’s where personnel from Doctors Without Borders, the International Red Cross and other aid organizations work – the part of the Ebola system most people are familiar with.

WHAT WAS THE LOCAL MEDICAL INFRASTRUCTURE LIKE?

Though extremely under-resourced by American standards, there is an existing public health surveillance system, just as in the U.S., where we have systems to count cases of diseases like influenza. In Sierra Leone, it had been used for diseases other than Ebola, like malaria and typhoid fever. The country also has an existing clinical medical system, which starts with very small health stations in many villages. In my district there were more than 100 of those, leading all the way to the government hospital in Makeni.

WHAT WAS THE EBOLA SITUATION WHILE YOU WERE THERE?

We investigated more than 800 patients with suspected Ebola, and more than half were confirmed with the disease. There were over 100 deaths, but that is probably an underestimate. There’s a delay in reporting deaths from ETUs, and some deaths in rural areas are not reported. By the time I left, the numbers in our district had begun to decrease. But in -areas around Freetown—the capital of Sierra Leone—cases are still on the rise.

WHAT WAS YOUR FIRST CONTACT WITH A PERSON WITH EBOLA?

I saw my first patient the day after I arrived, through a window in a holding center in Makeni. We could not go inside. We had three holding centers with a total of 140 beds, with a physical gradation according to patient risk. In the middle of each center were confirmed patients waiting transit to an ETU in another district. They were vomiting, had diarrhea and were very weak. Anyone who treated those patients, mainly nurses from Sierra Leone, needed to be in full protective gear in spite of the heat – near 100ºF – and high humidity. Those nurses were incredibly heroic. There was another section for patients waiting for blood test results, and a third for patients being observed for 21 days after their tests turned out negative. This separation of patients, and the nursing procedures, were all designed to minimize the risk that someone who was negative could get the disease there.

WHEN DID YOU WITNESS YOUR FIRST EBOLA DEATH?

It was the same morning. As many as eight people were dying some days.

HOW DID THE SURVEILLANCE PROCESS WORK?

We had about 100 college and public health students from Sierra Leone, mostly men, some women, whose classes had been cancelled because of Ebola. For now, school isn’t happening in Sierra Leone. They were the team’s disease detectives. Every morning they would ride their motor bikes out to respond to alerts that a household member was ill or had died. They would call an ambulance to remove the body or take the patient to a holding center. We had only four ambulances, so sometimes we would have to ask patients to walk to the holding center. We had to be very practical about it. Then the surveillance officer would talk to the family about who might have come in contact with the patient. These contacts would be followed for 21 days.

WHERE WERE THESE FAMILIES LOCATED?

Mostly in the south of the district, around Makeni. But some were in villages in the rural north. Many did not have electricity, and most did not have running water or flush plumbing. Unfortunately these conditions are conducive to the transmission of Ebola.

THESE INVESTIGATORS WERE GOING HOUSE TO HOUSE AND LITERALLY KNOCKING ON DOORS?

That is correct.

YOU SEEM TO HAVE GOTTEN CLOSE TO THOSE YOUNG PEOPLE. HAVE YOU STAYED IN TOUCH?

Yes, especially with a med student named Francis Abu Bayor. We worked side by side over there, and we’ve been emailing since. He was the leader of the surveillance team and in charge of our database on all the patients. He was an absolute optimist. His phrase was “challenge.” He would say, “Dr. John, we have a challenge” and that could mean anything from a new Ebola outbreak in a previously unaffected neighborhood to the printer being out of paper. Everything was just a challenge to be overcome.

IS HE STILL THERE?

He’s waiting for medical school to reopen. On my last day there, we gave him a stethoscope, which is traditional in medicine. My parents gave me one when I graduated from med school. Getting hold of a stethoscope was pretty convoluted. I ordered it from Amazon.com and had it delivered to a doctor in Atlanta who was coming to Sierra Leone. When he arrived in Freetown, he gave it to another doctor who was staying in my hotel. Then the three of us who had worked with Francis — Brigette Gleason, Tiffany Walker and I — presented it to him. He told me he was so inspired by his connection with CDC that he was going to make his career in public health.

WHAT WERE OTHER OBSTACLES YOU HAD TO OVERCOME?

Fuel was a constant problem because the investigators had to travel so far. So I put in a request to the CDC Foundation for fuel money, and it was granted. One of my jobs most afternoons was to take those fuel vouchers to the gas station and fill up the vehicles that were transporting the blood samples. And sometimes I’d fill up the investigators’ motor bikes as well.

WAS A SICK PERSON EVER RELUCTANT TO GO TO THE HOLDING CENTER?

Sometimes, at first. I helped in a few cases. We would talk to the head of the household and to the chief of the village. And we talked to the sick person, of course. To make sure I myself was not exposed to Ebola, I never passed over the threshold of a house. I’d ask the person to come out and we would talk from a distance in the street, usually a dirt path or road. Nobody was taken against their will, and I never saw anyone refuse to go. People were quite aware of Ebola because the education they had received had been very effective.

HOW DID FAMILIES REACT WHEN THIS HAPPENED?

It could be tragic. In some cases, it was the last time they ever saw their loved one. They would say goodbye in the house, and because they were contacts, they would have to remain there and be monitored for Ebola. Getting information on that patient in the holding center could be very difficult, though the surveillance officers tried. If the person turned out to be positive, he or she would be taken away to a distant treatment unit, where sometimes they died. Those were some very touching situations.

ONCE IN THE HOLDING CENTER, WHAT HAPPENED?

Patients with possible Ebola would receive medications for malaria and typhoid fever, intravenous fluids and also oral rehydration solution, which contains water, sugar and salt. And the blood draw would go as quickly as possible. That had to be done in full protective equipment. It’s quite a heroic job for someone to be drawing blood on Ebola patients all day long. Their dedication is hard to imagine. I was there 42 days, which I found very challenging, physically, mentally and emotionally. But the local health workers have been working like that for months.

HOW WERE THE BLOOD SAMPLES TESTED?

They had to be driven four to five hours to a CDC run lab in a town called Bo, which would email or telephone me the results. We had more than 800 samples sent for testing while I was there, and our goal was to have no more than 48 hours between someone’s lab test and learning whether they were positive or negative. It’s below 48 hours now, which considering the logistics is a real victory.

THEN WHAT?

There were many days when I would go to the holding centers to deliver blood test results to the nurses and help with the disposition of patients. If positive, we would get that person to a treatment center as quickly as possible, but it was three to four hours away. We, the lab and the treatment center were all in different locations. One way to conceptualize this is to imagine someone is suspected of Ebola in Dallas, has to be taken to Fort Worth to draw blood, then the blood is driven to Wichita, Kans., and if positive, the patient is transported from Fort Worth to Little Rock, Ark., for treatment. That is based on the actual drive times in Bombali.

HOW WERE THE ROADS?

Mostly dirt. It was the end of the rainy season, which meant that they were often mud. The vehicle carrying the lab samples crashed twice in one week because of road conditions. One of the scariest moments for me was hearing about those two accidents. I worried that there were unsecured blood samples at the site, but they were packed in a strong puncture-resistant container, and the samples were fine and were tested normally.

WHAT WAS THE CDC PRESENCE IN YOUR DISTRICT?

About 60 CDC personnel were in Sierra Leone at any one time, and we had seven staying in Makeni and working in Bombali and the adjacent district, Tonkolili. Six were doctors or epidemiologists, and one was a communications specialist because a vast part of outbreak control is educating people. We all stayed in the same hotel, and often ate breakfast and dinner together. Lunch was a PowerBar at our desks. Most everybody worked until midnight or 1 a.m., but one evening we all got together to relax and watch a movie I had on my laptop —Die Hard—and some of the hotel employees watched too. It was a nice diversion. I felt extremely close to the CDC colleagues I was working with.

ANY CHANCE TO EXERCISE?

Four or five times a week, I got on the elliptical at the hotel for an hour at the end of the day. It didn’t plug into the wall, didn’t need electricity. So when the power went out, which happened frequently, I kept going in the dark. The other people in the gym would laugh, but exercise is very important to me, both at home and traveling. When the lights were on, I was on my BlackBerry most of the time on the elliptical. That was routine multi-tasking.

HOW DID YOU PROTECT YOURSELF FROM EBOLA?

The most important thing was no touching. No shaking hands, no hugging. It was a massive societal change. I’d never been to Sierra Leone before, but I’d heard that the people are affectionate and physical. It was really something to live in that reality where you never touch another person — except a couple of times when I inadvertently bumped into someone at a meeting. Also, before being posted, we were trained at CDC in Atlanta in the use of personal protective equipment which all of us carried in backpacks at all times. Fortunately I never needed to put mine on.

DID YOU EVER GET SICK OVER THERE?

I got mild food poisoning after a weekend trip to CDC headquarters in Freetown. At first, I didn’t know what it was, but I followed all our established procedures. I isolated myself in my hotel room for 24 hours. We had a supply of MREs [meals ready to eat] so I didn’t have to leave. I checked my temperature and reported it to my supervisor so a decision could be made as to how to handle it, depending upon the symptoms, and if needed, discussions with Atlanta. My symptoms went away quickly, and I never had a fever. It wasn’t Ebola.

WHAT WERE BURIALS LIKE?

Every person who died, no matter what the circumstances were, was supposed to be tested for Ebola with a cheek swab and then buried safely. The body was quickly placed in a body bag, which was sprayed with chlorine by a protected burial team. Then it was taken to a new and separate communal cemetery especially set aside for this purpose. To the burial teams’ great credit, they were extremely respectful. Families could not say goodbye at a funeral and could not be at the burial, but could wait nearby. And after the ground was also sprayed with disinfectant, loved ones could leave small memorials and markers there. Seeing that cemetery was one of the most moving experiences of my entire life.

THESE WERE HIGHLY EMOTIONAL MOMENTS. DID YOU EVER FIND YOURSELF IN TEARS?

I did cry a couple of times, but only in the evenings at the hotel, not in public. I think most of the CDC workers cried at one time or another. All of the CDC people supported one another a great deal, because everyone realized how stressful it was. So I never felt alone. I felt emotional very frequently, and tears were close, but the days were so busy and long that I was able for the most part to keep my attention on the matters at hand.

DID YOU FINALLY GET ACCUSTOMED TO THE DANGER?

I never felt personally threatened, but of course my risk was not zero. To keep it at zero, I would have had to stay home. We were all accepting some level of risk. But it was more the constant psychological cost of having to worry about it, of never touching people, maintaining distance, having to stay disconnected from potential patients. It was like a blanket over all our activities. On a human level, it was very difficult, many hours a day, seven days a week, and it was frequently very sad.

WHAT WAS THE FEELING ABOUT AMERICANS THERE?

I didn’t feel a negative vibe even once. People said thank you routinely. It was really touching. When I spoke to the young men and women we were working with, I would emphasize that we were brothers and sisters in the fight against Ebola. We were all on the same team. I think that’s the way everyone felt.

HOW DID YOUR OWN FAMILY FEEL ABOUT YOUR ASSIGNMENT?

They were very supportive. My wife, Bernie, actually encouraged me to go to Sierra Leone. She is a physician herself and understood both the gravity of the situation and the contribution I could make to it. Most deployments are for 29 days, and when the CDC asked me to stay longer, she said it sounded like a good idea. We kept in touch mostly by email, but I bought a local phone card and we talked a couple times each week. The connection wasn’t bad. I was able to see my daughters at college on Skype from time to time. It helped that they didn’t seem worried. When we talked or e-mailed, I tended to emphasize the positive aspects of what we were doing and minimized the sad things I’d seen.

NOW THAT YOU’RE BACK HOME, ARE YOU IN QUARANTINE?

Technically, I was not. I was in a category that’s called low risk, but not zero risk for 21 days. I had to report on my temperatures twice a day to both the state of New Mexico and CDC. I wasn’t supposed to go to work, but Sandia National Laboratories was very supportive and understanding. I am detailed there by CDC as an epidemiologist on their International Biological Threat Reduction team. I could leave home briefly to buy food or something like that, but my wife was happy to take care of those things. I was told to report any illness or symptoms immediately. It ended November 19, and I’m fine.

WHAT DID YOU LEARN IN SIERRA LEONE?

As a physician, I learned how quickly someone can get terribly sick from Ebola and die. As a medical epidemiologist, I saw that the public health efforts to which CDC is contributing are going to be what eventually ends this outbreak. As a human being, I learned how hard working, brave and heroic my Sierra Leonean colleagues were. At no time did I feel that what I was doing was futile. Ultimately, what I really learned about Ebola is that it is controllable.

WOULD YOU GO BACK?

Without question.