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Vol. LXVII, No. 7
March 27, 2015

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On Ebola’s Front Lines
NIH’ers Among First Commissioned Corps Deployment To West Africa Outbreak

On the front page...

In Liberia, Lcdr. Rafael Torres-Cruz of ORS was one of 7 NIH’ers deployed.
In Liberia, Lcdr. Rafael Torres-Cruz of ORS was one of 7 NIH’ers deployed.
Disaster struck more than 5,000 miles away. West Africa was in the midst of the worst Ebola virus outbreak in history. The deadly epidemic, begun in December 2013 in Guinea, spread quickly to neighboring Liberia and Sierra Leone by March 2014. Several factors complicated containment of the disease, including extreme poverty, political instability and a dysfunctional health care system. By last summer, the outbreak threatened several nations outside of Africa, becoming a global emergency health crisis.

Last October, the United States took an extraordinary step to address the crisis, beyond the already sizable response in U.S. resources—medical, scientific, logistical and financial. The U.S. Public Health Service assembled a team of 69 Commissioned Corps officers to deploy to the Monrovia medical unit (MMU), just outside of Liberia’s capital city. Seven NIH’ers were among those selected for the team. Back at home now, a few of them shared details from the experience.


Different Kind of Deployment

Several factors made this deployment unique, according to NIAID’s Dr. John Pesce, a lieutenant in the corps.

“First, the length of the deployment was beyond the normal 2 weeks,” he said. “Second, this team was handpicked from the best of the best of the current officers. Third, this is the first time the [corps] has ever deployed to respond specifically to a disease outbreak. We have responded internationally in the past—Haiti earthquake, Indonesian tsunami, Japan earthquake—but never in our history have we been recognized as being the specialized medical team that can focus on the treatment of a specific disease.” The Commissioned Corps is the only one of the 7 uniformed services (Army, Navy, Air Force, Marines, Coast Guard and National Oceanic and Atmospheric Administration) with a mission that specifically addresses public health, Pesce pointed out.

This first group, “Team 1,” was assigned to serve from Oct. 19 to Dec. 21— 61 days—more than 4 times the usual deployment period.

In addition, noted Lt. Cmdr. Rafael Torres-Cruz of the Office of Research Services, it was the first time the corps “had the lead role and main responsibility for the success of a mission during an international crisis in response to a

United Nations’ request to support the Liberian government and, more specifically, the Liberian health ministry.”

Learning of the upcoming assignment, many NIH’ers volunteered.

“I have participated in a few deployments in the past—Hurricane Sandy 2012 and Unaccompanied Minors 2014—and there was no way I was going to be left out of this one,” Pesce said. “As soon as I found out they were assembling rosters, I contacted the officers in charge and requested to be on the first team.”

NIH’ers deployed with Team 1 to the Ebola crisis in Liberia are (from l) Torres-Cruz, Cdr. Robert Horsch of ORS, Lt. Michelle Holshue of the Clinical Center, Lt. Shane Deckert of ORF, Cmdr. Michelle Braun of NIDDK, Cmdr. Gregg Gnipp of ORF and Lt. John Pesce of NIAID. The survivor wall

NIH’ers deployed with Team 1 to the Ebola crisis in Liberia are (from l) Torres-Cruz, Cdr. Robert Horsch of ORS, Lt. Michelle Holshue of the Clinical Center, Lt. Shane Deckert of ORF, Cmdr. Michelle Braun of NIDDK, Cmdr. Gregg Gnipp of ORF and Lt. John Pesce of NIAID.

At right, the survivor wall

Lt. Michelle Holshue of the Clinical Center was also eager to go. “As an infectious disease nurse, the opportunity was a dream come true,” she said.

“This is what we do,” said Cmdr. Michelle Braun of NIDDK. “The [corps] responds to public health needs both at home and abroad. NIH officers are fortunate that our agency leadership and colleagues support us by taking care of our NIH responsibilities while we are deployed.”

Preparing to Go

Before traveling to Liberia, the team was sent on a week-long intensive training and orientation session at the Center for Domestic Preparedness in Anniston, Ala., where they were lectured on safety, infection control and other topics relevant to working in an Ebola treatment unit. They participated in hands-on drills for dressing/undressing in protective gear, received a number of extra vaccinations and underwent multiple health screenings as part of their State Department physicals. Team members were also briefed on stress management, terrorism, life in Liberia and were advised about putting their home and family affairs (will, power of attorney) in order.

“Training prior to leaving for Anniston included clinical information about the Ebola virus, the current outbreak and the response at that point in time,” said Braun, who has been on more than 10 deployments, national and international. “Survival, evasion, resistance and escape—‘SERE’—a Department of Defense training component, was also required. The training for this deployment far exceeded any previous pre-deployment training required.”

‘Hooch’ Life

Horsch gets ready to be fit tested for a respirator.
Horsch gets ready to be fit tested for a respirator.

Lt. Shane Deckert of the Office of Research Facilities described the scene they found in Liberia.

“We arrived at the end of ‘wet season,’ which was basically monsoon season, then transitioned into the ‘dry season,’” he explained. “Every day was very hot and humid and my job revolved around me being outside…designing and building items for the hospital as the lead engineer. We ate meals ready to eat—MREs—for 35 days straight…We slept 11 to a 2-bedroom ‘hooch,’ a tiny concrete house.”

Pesce had expected certain rustic conditions. “I knew we were going to a developing country that was recovering from internal conflict,” he said, “but I don’t think I was really prepared to see such abject poverty. I had never been to Africa or a developing country so I was certainly taken aback at how poor some people in this world really are. There is little electricity and even less sewage removal. You cannot drink the water because it is likely to make you sick, so you always drink bottled water and even use it to brush your teeth. It really made me appreciate the basic things that we have here in the U.S. that all of us take for granted.

“We worked 12-14 hour shifts,” he continued. “Typically, I would get back to my hooch at the end of the day, take a shower and shave and then crash in my cot for 5-6 hours before the day started over. This was pretty much every day for the first 50 days of the deployment.”

Thanksgiving, for Real

“Borrowing from a Liberian colloquialism,” Braun said, “‘It’s not easy. Once you adjust to the surroundings, you appreciate what you have and adapt.’ Team members take care of each other by sharing—food, possessions and things learned on prior deployments—to make things more comfortable.”

Holshue agreed, “Our living and working conditions were certainly austere. We slept in communal housing on military cots at first, and then eventually moved into large, 20-person tents when our camp was constructed next to Roberts International Airport. Our hospital facility was also a series of large tents with plywood floors—very sparse. We didn’t have access to hot meals for more than a month...One of our first hot meals was for Thanksgiving dinner, and we ate on these huge tables made out of plywood. It was challenging, but looking around the table at our MMU family as we sat down to dinner that night, I realized we had so much to be grateful for.”

In the Trenches

Holshue said on a typical day, team members “would complete our work in shifts—nurses would always go into the high-risk area in pairs. It took about 30 minutes to get the personal protective equipment (PPE) on and prepare for our patient care. And there is a time limit to how long we could physically endure wearing the PPE—generally we’d have about 1½-2 hours to get all of our work done. After we finished with patient care or exceeded our time limit, the doffing—undressing—process took another 15-30 minutes. A safety officer would walk us through the process, step-by-step, spraying us down with chlorine as we took off each layer of protective gear…After our rotation, there were always things to do—preparing for a patient discharge or admission, restocking supplies, checking inventory levels, cleaning our workspaces. The days went by quickly. At our busiest, we worked 6-7 days a week.”

Horsch and Pesce build tables. Braun helps an officer get dressed for duty.

At left, Horsch and Pesce build tables. At right, Braun helps an officer get dressed for duty.

Noted Braun, “The level of attention required to safely enter, work and exit the Hot Zone is unlike anything we had ever done in our nursing careers. Everyone has to remain focused at all times to protect the team from exposure and provide care to our patients.”

For his part, engineer Deckert said he spent a lot of time on do-it-yourself home improvement projects.

“My typical day consisted of reflecting on the status of our Monrovia medical unit and designing ways to better our hospital and our unit morale while on the [hour-long] bus ride to work,” he said. “Once I got to work, I got right to work building those items. Just about every day of the 2-month deployment, I was outside figuring out solutions to our engineering problems and working with [Pesce] to fix them. Lt. Pesce was my ‘honorary engineer’ and helped me design and construct things and also taught me a ton about woodworking.”

Items they built from scratch included a rack for their muck boots to dry on, covers to protect their water supply, benches to use when changing from uniforms into scrubs, bedside tables for patients (designed by Pesce), a field shower made with catheter bags and a spray pump, a drainage ditch to catch the contaminated water runoff from the hospital, stairs to allow better access to chlorinate the water tanks, a pull-up and dip bar to allow workouts and tables to hold mission-essential hand-washing stations.

After 6 weeks, Pesce was transferred to the safety/preventive medicine unit due to staff shortages there. He worked the same hours but his responsibilities changed. His new role? Safety person for the doctors and nurses treating the patients.

“I would ensure they had a safe environment to work in—cleaning toilets and cleaning vomit up off the floor—and ensure that when they performed any procedures that they were doing them safely and that there were no accidental exposures,” he said.

“[The team was] extremely well trained and more than up to the task at hand, so fortunately my job was just to be an observer most of the time,” he continued. “I would suit up once or twice a day for about 2-hour shifts. This may not sound like a lot, but it is absolutely exhausting. The temperatures are brutal and you cannot stop sweating. It was typical for me to lose several pounds in a 2-hour shift just from sweating. This means you need to have recovery and rehydration time before your next shift. And on top of all this you have to remember that the very room you are in and the patients you are treating are contaminated with Ebola, so not only is it physically draining it is also mentally draining because a mental mistake can be lethal.”

Impact, Professional and Personal

The mental and emotional tolls were perhaps the steepest hurdles for team members. “The most difficult part of the experience was losing a patient,” Holshue noted. “We were caring for health care workers who got infected with Ebola because they were on the front lines of this epidemic. These were the true heroes of this massive worldwide effort. So when a patient succumbed to Ebola, it wasn’t just losing a patient—they were our colleagues, our heroes.”

Cmdr. Robert Horsch, an ORS industrial hygienist, agreed. “Watching the fear of patients entering the MMU as if assigned a death sentence…Death of patients was very difficult to experience. However, watching patients survive extreme disease was overwhelming.”

At the survivor wall is co-creator Holshue, a CC infectious disease nurse who returned to Liberia Mar. 2. Via email she says, “I’m here to work on the clinical trials that NIH/NIAID are running! I’m so happy to be back!” Deckert (r) gives a fellow officer a briefing on construction at the Monrovia medical unit.
At the survivor wall is co-creator Holshue, a CC infectious disease nurse who returned to Liberia Mar. 2. Via email she says, “I’m here to work on the clinical trials that NIH/NIAID are running! I’m so happy to be back!” Deckert (r) gives a fellow officer a briefing on construction at the Monrovia medical unit.

“Never have I known someone for such a short period of time, yet instantly know they will be with you forever,” added Braun. “As devastating as the negative outcomes were, seeing survivors reunite with family was an amazing experience.”

To mark the good times, Deckert, Holshue and Pesce fashioned a survivor board. “The best thing was when our patients survived and we were able to discharge them from the MMU,” noted Holshue. “All of our staff would gather outside and we’d have a big celebration when the patient would emerge from the exit. We had a ceremony with a wall where survivors would place their handprints in bright yellow paint. It said, ‘Today I Am Healed—Tomorrow I Return to Heal Another.’”

The muck boot rack fashioned of necessity
The muck boot rack fashioned of necessity

The current outbreak seems to be slowing, although the total lives lost in one nation alone is still enormous. As of Mar. 4, according to the Centers for Disease Control and Prevention, Liberia has experienced an estimated 9,249 Ebola cases; 4,117 deaths in the country have been reported from the deadly virus.

Torres-Cruz, who as night-shift chief of safety fulfilled the role of gatekeeper of the Hot Zone, recalled, “Many great things happened during the mission, probably the first one was a night when I was inside the MMU and saw two of our confirmed patients out of bed walking around and smiling. Immediately I knew that they were getting better. At that time I realized that all this effort was not in vain. They eventually were the first two survivors that left the MMU.

Also, we got a call from President Obama and a visit from the Liberian president. The worst was probably when we first lost a patient due to Ebola. At that moment reality hit us in our face and we realized how destructive this virus is.”

Describing the personal as well as professional impact, Pesce concluded, “As a scientist, we often don’t get to see the tangible fruits of our efforts. By participating in this deployment I got the chance to see that what I did made a difference and improved the lives of others. Additionally, I made 68 new friends who have truly become family to me. Despite the hardship and sadness this was one of the best experiences of my life.”

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