Mike’s Liberia Journal
Feb 20, 2021
Week two started off with a bang. Sunday morning, a press release came out declaring an outbreak of Ebola on the Guinea/Liberia border. This is the same place it started last time, a four hour drive from us in Monrovia. This was obviously bad news. We increased precautions at our hospital, moved triage outside, and hoped for the best. By Wednesday, suspected cases had made it to Monrovia.
As happened last time, once Ebola is around and in healthcare facilities, people are afraid to seek care at those facilities and travel elsewhere. This makes sense…I wouldn’t want to get treated at an Ebola hotspot, either. But this causes the disease to rapidly spread outside of the initial outbreak since some of these travelers are unknowingly sick with Ebola. The 2014 Ebola outbreak actually started in December of 2013 and was in Liberia as early as March of 2014, but the numbers stayed very low until June. They were all in the bush – rural areas in the region that share borders with Guinea, Sierra Leone, and Liberia. In June 2014, a woman in Sierra Leone fell ill and got in a taxi headed to Monrovia. The epidemic was much worse in Sierra Leone and Guinea at that point, so she headed away. She arrived at the facility where I was working, and within two weeks Ebola was running rampant in Monrovia.
This time, the patient was from Guinea. She arrived to a clinic in Monrovia with symptoms of Ebola. She and her contacts were immediately isolated, treated for symptoms, and tested for Ebola. Test results are pending, but we are all certainly on high alert. Luckily, Liberians are familiar with and appropriately terrified of Ebola. Locking things down was much easier this time.
On Monday, we started our main hospital project of the trip – upgrading the lab.
Quality laboratory testing capabilities are lacking throughout Liberia. When we opened the hospital, we decided two of our main foci for areas of excellence to have the greatest impact on healthcare for Liberians would be respiratory care and laboratory services. Respiratory care was easy; it is what we’ve been doing for years, we have the workforce and the training college. The lab has been trickier. Supply chain in Liberia is tough; even if you can find laboratory equipment in country or bring it over, you may not be able to maintain it. Most laboratory machines require proprietary calibration fluids and testing reagents that are not readily available in country. Even when they are available, they tend to have short expiration lives and require strict storage conditions (refrigeration, darkness, etc). Most healthcare centers in Liberia have a tomb of laboratory equipment that is fully functional, just not serviceable. Indeed, we inherited laboratory equipment worth several hundred thousand dollars from an Ebola research group that we cannot use for these reasons.
We have approached this problem from two angles: quality manual tests and sustainable technology. Many of the most important lab tests can be done manually by a well-trained laboratory technician. Things like malaria testing, hematology, and urinalysis, for example, can be done with a microscope and some basic stains, so we hired Ibrahim, an expert who trained in Liberia and is used to doing manual tests. Manual tests have limitations, however – more complex testing cannot be done manually, and the tests that can be done manually tend to take a long time. For instance, a manual hematology assessment takes approximately an hour. This is not feasible in a busy center like ours, so we needed sustainable technology options.
The first device we brought over was an iStat®. An iStat® is a pretty amazing gadget. It came out about twenty years ago and it still unparalleled on the market. It is about the size of a 1980s cell phone, battery powered, and can run full chemistry/metabolic/respiratory panels on a few drops of blood in under three minutes. Even better, it requires zero reagents. It requires a small chip for each sample, similar to a glucometer for diabetes. These chips aren’t a perfect solution – we have to buy them (not cheap), get them to Liberia, and they only have a few months of shelf-life. But, once we have them in country, they are pretty robust. Also, the test process is extremely user friendly; Ibrahim can train just about anyone to run them while he focuses on more complex procedures. So, the iStat® is pretty great. I brought over several hundred chips this trip that should cover us until my next trip and updated the iStat®, so we should have a functional chemistry/metabolic/respiratory lab unlike any other in the country for at least four months. Unfortunately, the iStat® cannot do hematology panels.
This trip, we brought over something really exciting. Scott found a device called the Olo®. This is a “dry” hematology machine. It’s roughly the size of a shoebox, requires no reagents, and, similar to the iStat®, just needs a chip and a few drops of blood to do a full hematology panel. Even better than the iStat®, no updates are needed and the chips have a 13 month shelf-life. The device may also be used to detect malaria, sickle cell, and other blood disorders. This technology is brand new; in fact, this is the first unit on the African continent. The company, Sight Diagnostics, is quite excited to see how it performs and has been incredibly helpful (and generous). Instead of a manual hematology panel requiring an hour of Ibrahim’s undivided attention, this chip takes about a minute to load and the machine spits out the results in ten minutes.
By the end of the week, we had a fully functional, state-of-the-art laboratory at our hospital.