The recent Ebola Virus Disease (EVD) epidemic in West Africa was the largest in history, with over 28,000 suspected cases and more than 11,000 deaths.1 Liberia, where over 4,800 people died between 2014 and 2016, was one of the countries hardest hit by the epidemic.1 The size and complexity of the outbreak required a coordinated international humanitarian response—especially from the health care sector. The crisis required experts from the scientific, public health, and medical communities to work in concert with local governments and international aid organizations to bring the epidemic under control.2
In the autumn of 2014 when the epidemic was expanding rapidly across Liberia, Sierra Leone, and Guinea, experts trained in the fields of infectious disease, disaster management, and critical and emergency care were desperately needed to staff Ebola treatment units (ETUs). Many of these experts were employed by U.S. academic medical centers (i.e., teaching hospitals and their affiliated medical schools; AMCs); however, many U.S.-based physicians and nurses faced barriers preventing their critically needed deployment to and involvement in West Africa.3,4 The lack of response from U.S. AMCs created much controversy5 and inspired a dialogue about both the role AMCs should play in this response and what mechanisms needed to be established to allow faculty and staff from these institutions to work in West Africa.6–8
We authors are members of a collaboration, the Academic Consortium Supporting Medical Education in Liberia (ACSMEL), which was founded in 2008. ACSMEL comprises U.S. AMCs and other medical institutions that work together to support medical education and physician workforce capacity building in Liberia. ACSMEL’s long-term partnerships in Liberia with the national medical school and the Liberian College of Physicians and Surgeons have facilitated our involvement in the international EVD response. We describe here the role that this academic consortium played in responding to the EVD outbreak in Liberia, the barriers that ACSMEL-member AMCs had to overcome to enable participation, and the factors that contributed to success. We also discuss lessons learned and suggest ways in which U.S. AMCs can successfully participate in international disaster responses in the future.
Before the Ebola Outbreak: Support of Medical Education and Workforce Capacity Building in Liberia
The civil wars that took place in Liberia from 1989 until 2003 effectively destroyed 70% of the medical clinics and hospitals in the nation, drastically depleting the physician workforce. At the end of the civil wars, only about 50 physicians were practicing in a country of 3.9 million people—1.3 physicians per 100,000 population.9 This ratio represents one of the lowest physician densities in the world.9 In addition to this shortage of clinicians, Liberia also faced a shortage of medical school faculty members to teach the basic sciences and provide clinical training.
Between 2009 and 2013, ACSMEL sent more than 100 faculty members, residents, and fellows to teach and train Liberian house staff and medical students. ACSMEL collaborated with the aforementioned Liberian College of Physicians and Surgeons and the publicly funded AM Dogliotti Medical School at the University of Liberia to support clinical medical education and to help create postgraduate training programs in the fields of internal medicine, pediatrics, obstetrics–gynecology, and surgery.10 In September 2013, the Liberian Post Graduate Medical College welcomed its inaugural class of residents into the first residency training programs available in Liberia since before the civil conflict in 1989.
During the Ebola Outbreak
When the EVD epidemic began in Liberia in March 2014, all U.S. faculty, residents, and fellows from the consortium were restricted from returning to West Africa because of the risk of contracting Ebola. Liberian faculty and trainees were left to work on the front lines of this deadly epidemic without ACSMEL members’ support. As the epidemic progressed, residency training programs and the national medical school shut down. Insufficient numbers of faculty members remained to teach, and hospitals were under siege, reacting to and trying to treat patients with Ebola.
Many Liberian medical students and residents left their training to assist their country either by working in ETUs or supporting international aid agencies. Health care workers on the front lines of the epidemic were placed at extremely high risk of contracting the virus. Sadly, Liberia lost 8% of its already-limited health care workforce during the epidemic.11 Among those lost were Liberian medical students, residents, and clinical faculty with whom we had worked closely over the years.
Early efforts to support Liberian health care workers during the EVD epidemic
Throughout the epidemic, the need to provide our Liberian colleagues with personal protective equipment (PPE) was urgent; they were working on the front lines without adequate protection. In the summer of 2014, after the epidemic began, we worked to procure and ship critically needed materials. We approached vendors who supplied ACSMEL-member hospitals with surgical gear and were successful in collecting over a ton of EVD-appropriate PPE including gloves, gowns, masks, and boots. Shipping costs—over $50,000—were substantial and could have become a barrier to supplying the necessary materials; however, donations from local Liberian societies and private donors helped cover the expense. Funds raised through an online crowdsourcing campaign also supported shipping. The PPE materials were distributed at the national referral hospital (JFK Medical Center) in Monrovia, where many resident and student trainees work.
Scaling up to a country-wide humanitarian relief effort: PPE and Ebola training at government hospitals
As the epidemic expanded, we learned of ongoing shortages of PPE and health care worker deaths at many sites outside of Monrovia, Liberia’s capital. We sought to expand our efforts to provide PPE for health care worker protection and to offer infection prevention and control (IPC) training throughout Liberia. To meet these needs, we began to search for larger funding mechanisms to support our emergency response.
In October 2014, we were fortunate to receive generous grant support from the Paul G. Allen Family Foundation #TackleEbola campaign. Using #TackleEbola grant funding, we were able to scale up to deliver a comprehensive emergency IPC response to all 21 government hospitals in Liberia (see Supplemental Digital Figure 1 at http://links.lww.com/ACADMED/A490). This intervention, delivered from December 2014 to March 2015, was in synchrony with other major international nongovernmental organizations (NGOs) that were also responding to the outbreak. At this point, since we added new partners to aid in our response, we changed the name of our academic consortium to the Academic Consortium Combatting Ebola in Liberia or ACCEL.
For our large-scale response, we purchased $1.9 million worth of PPE and arranged $400,000 worth of in-kind air shipping to deliver the materials to Liberia. The 70 tons of PPE were enough to supply each of the 21 government hospitals with a three-month supply of context-appropriate PPE.
In addition to the delivery of this PPE to each of the 21 hospitals, ACCEL assembled IPC training teams who delivered the national IPC training package and supported its immediate implementation at the hospital level. The training teams consisted of Liberian physicians; nurses; midwives; psychosocial clinicians; and water, sanitation, and hygiene technicians—some of whom had been our Liberian collaborators and/or students in the past. Liberian health care workers were eager to participate in the international response to the epidemic.
To accomplish the daunting tasks of procuring and delivering such a large shipment of supplies and marshaling teams for IPC training to all 21 hospitals (some of which were located in extremely remote locations), we partnered with the Humanitarian Response Lab in the Massachusetts Institute of Technology (MIT) Center for Transportation and Logistics. MIT and its partner (Avenir Analytics) supplied the expertise necessary to assist ACCEL in overcoming logistical obstacles and helped to create a supply chain that was expedient and efficient.12 The rapid scale-up of this supply chain relied on training and working intensively with a capable in-country logistics staff.
Our country-wide IPC intervention established both PPE and IPC practices in Liberian hospitals and was, therefore, a major factor in bringing health care workers safely back to work in the nation in March 2015. Since the start of this intervention in December 2014, no hospital-based health care worker supported by ACCEL has contracted EVD in Liberia. This nation-wide public health response also facilitated the placement of faculty at Liberian hospitals to restart training programs and ensure the safe return of Liberian trainees.
Faculty support to ETUs
At the height of the epidemic in November 2014, Ebola patients were filling the ETUs, and health care workers were desperately needed to help staff them. To assist in these efforts, we engaged ACCEL’s academic partners to recruit physicians, nurses, and other health care personnel from their institutions and professional networks. We were especially interested in recruiting individuals with expertise in infectious disease management, emergency medicine, critical care, and disaster response.
In recruiting U.S. faculty to join the Ebola response, we faced many administrative barriers, often put into place by AMCs and their affiliated clinical systems. The high mortality rate associated with EVD, the limited availability of care, and the exorbitant expense of medical evacuation and medical care resulting from infection exceeded the coverage of many medical insurance or workers’ compensation policies. We employed a variety of techniques to overcome these challenges (Table 1). We formed a partnership with major international NGOs including International Medical Corps and the International Rescue Committee, both of which were providing Ebola treatment. The NGOs hired ACCEL-member institution faculty and nurses and trained them to work in their already-established ETUs. NGOs also paid salaries and offered benefits such as evacuation insurance and workers’ compensation insurance. These benefits were instrumental in alleviating the administrative barriers that clinicians from the consortium faced. Some institutions in the consortium opted to purchase additional workers’ compensation insurance for key employees who would be traveling frequently to West Africa. Others offered their employees a leave of absence while maintaining their benefits (e.g., health insurance) for their families.
In an effort to recruit critically needed health care workers to work in ETUs, we held informational sessions at ACCEL-member institutions and sent e-mails through listservs to access our professional networks. We had a robust response to our recruitment efforts; over 40 U.S. AMC-based physician and nurse volunteers responded to the call for health care workers. Because the need for volunteers in Liberia was slowing in January 2015, only three of our physicians were contracted for service by our partnering NGO, International Medical Corps, to work in ETUs. One of these faculty members returned to Liberia a second time to assist in IPC training of ETU volunteer recruits.
Reactivating medical training programs
Faculty support to government teaching hospitals.
As a broader spectrum of care resumed at government hospitals in March 2015, we recruited for clinician educators from within ACCEL-member institutions and through our networks. We wanted Liberia’s clinical training programs to resume, so we sought educators who could both provide direct patient care and teach resident trainees and medical students. We worked closely with the Liberian Post Graduate Medical Council and chairs of clinical departments in Liberia to determine which types of faculty were needed at each of four teaching hospitals. Many U.S. AMC-based faculty (P.A.M., M.N., E.A.G., L.R., and J.T.) who had worked in Liberia through the consortium in the past again volunteered for these efforts despite the still-present threat of Ebola.
On arrival, all faculty received IPC training and were given up-to-date information on how to protect themselves from EVD while working clinically. Safety and security were top considerations in choosing sites for faculty placement. Housing and transportation were also important, and our logistics partners, the MIT logistics team, helped us arrange local transport and room and board. Each faculty volunteer was placed at one of four teaching hospitals in Liberia: (1) JFK Medical Center, the national referral hospital; (2) Redemption Hospital, the country’s largest public hospital; (3) Phebe Hospital in Bong County; and (4) Jackson F. Doe Hospital in Nimba County (see Supplemental Digital Figure 1 at http://links.lww.com/ACADMED/A490).
We placed 33 clinical faculty members and 2 nurses. The faculty were from a variety of specialties and spent varying amounts of time in Liberia—ranging from two weeks to nine months, depending on clinical need and availability. The faculty members participated in clinical and didactic teaching within their specialty area. In addition, faculty designed a variety of innovative clinical training programs, including courses in pediatric advanced life support and advanced cardiovascular life support. Faculty focused the training on how to perform key functions safely in an environment where EVD was endemic. One group of emergency medicine faculty offered a longitudinal clinical ultrasound training program appropriate to the EVD-endemic context for residents from all four residency training programs.
Challenges involved in this phase of the epidemic response included securing housing and transportation for faculty who would be placed at the teaching hospitals. ACCEL-member AMCs did not have the mechanisms in place, nor were they able to take on the risks associated with renting vehicles, providing housing, or paying local staff in a foreign country. For these in-country operations, we worked through subawards with ACCEL’s in-country partner, the Liberian College of Physicians and Surgeons (see Tables 1 and 2).
Faculty support to the national medical school.
By July 2015, the AM Dogliotti Medical school had been closed for an entire year because of a lack of faculty. We worked with the dean of the medical school to help recruit temporary basic science faculty to reopen the medical school for the following academic year (2015–2016). Some of these faculty were recruited from the basic science departments of ACCEL’s member institutions. We also formed a new alliance with an African AMC, the Addis Ababa University School of Medicine (AAU) in Addis Ababa, Ethiopia. AAU was instrumental in this phase of the intervention as it was able to provide many hard-to-find basic science faculty to fill critically needed positions. Indeed, AAU’s involvement was largely responsible for the reopening of Liberia’s national medical school in September 2015. We found that our African partners faced far fewer administrative hurdles and, for this reason, were much freer to participate in this phase of the EVD response in West Africa.
Despite the disruption caused by the EVD epidemic, most medical students returned to school, and the largest first-year class recruited to date, consisting of 60 students, started in September 2015.
We describe here how our collaboration of U.S.- and African-based AMCs was able to play a unique and vital role in the EVD relief efforts in Liberia. The initiatives to bring needed supplies and training (IPC) began as grassroots efforts to supply PPE to help protect our Liberian colleagues, but transformed with generous funding into an important component of the international humanitarian response. Our experience raises questions about the roles U.S. AMCs can or should play in humanitarian and disaster response.
There is a precedent set for U.S. AMCs lending support during humanitarian crises. One means of response is the deployment of Disaster Medical Assistance Teams (DMATs). DMATs consist of faculty, based at AMCs throughout the United States, who are deployed through the federal (U.S.) National Disaster Management System to provide a coordinated response to domestic disasters. The response to Hurricane Katrina in New Orleans in 2005 is one example of these coordinated relief efforts.13
In the international arena, defining a role for U.S. AMCs as stand-alone agencies in humanitarian response efforts has been much more complex. The response to the earthquake that occurred in Haiti in January 2010 is a good example of this complexity. A large number of disaster management and surgical teams from various U.S. AMCs deployed to Haiti to aid in the response.14–16 While all were well intentioned, few were able to collaborate to provide an integrated, coordinated response, and many of the faculty, physicians, and others who rushed to the scene did so in parallel, duplicating or confusing efforts, rather than complementing and coordinating them. Some institutions were unprepared to support their own team’s personal and operational needs, straining local resources. This haphazard response contributed to an ineffective use of resources and inappropriate delivery of care—not to mention distraction from the response (as those on the ground had to support responders).
Another contrasting example of assistance to Haiti after the earthquake involved a long-term relationship between the American Academy of Pediatrics (AAP) and the Haitian Pediatric Society (HPS). In this case, the assistance was coordinated and effective. Like Liberia, Haiti suffered a large loss of faculty in the wake of the earthquake. In response to requests from the HPS, the AAP was able to facilitate an initiative by which many faculty members from several U.S. AMCs traveled to Haiti to support medical education and clinical training programs. The success of this effort demonstrates how long-term partnerships can be leveraged during times of humanitarian crisis.17
Our experience working in Liberia during the EVD epidemic provides valuable lessons about the participation of AMCs in humanitarian response efforts:
- Long-term international academic partnerships, including faculty who have situational knowledge of the precrisis context, can be extremely useful in humanitarian response efforts.
- Collaborating with a local AMC (in our case, an African AMC, AAU), complements response efforts.
- Taking steps to mitigate risks allows for faculty involvement in humanitarian and disaster response. We believe that AMC administrators and leaders of clinical systems have a responsibility to find solutions to risks, thereby releasing faculty with valuable expertise and experience to assist in the humanitarian response.
- For a direct field response, AMCs should consider deploying only faculty members who have relevant disaster or humanitarian crisis training and appropriate logistical support. Deploying only trained personnel who have the necessary on-the-ground resources allows the AMC to assist with relief efforts and precludes the response team from becoming a significant burden.18 Partnering (as we did) with NGOs with disaster response experience and employing a logistics team (like the MIT team) well versed in humanitarian response helps response teams achieve their goals.
- Planning to integrate into the country’s (in our case, Liberia’s) coordinated response and not act in parallel is vital. Working in coordination with other NGOs and stakeholders who are involved in the response is vital to avoid duplication or confusion. This collaboration can best be accomplished by integrating into the framework set out by national or international leaders (e.g., members of the local ministry of health or personnel from the U.S. National Disaster Management System).
AMCs have valuable resources to offer in humanitarian crises, including the ability to leverage funding and faculty members with expertise and experience in basic and clinical sciences. Conversely, AMCs, if unprepared, can actually hinder or slow the humanitarian response. Faculty with disaster experience should be called on to volunteer to lend aid; a logistical team should help deploy local resources, including housing and transportation; institutional leaders should identify the areas of potential benefit and risk, carefully weigh the decision to participate, and work to mitigate risk; and local partners with knowledge of the context and on-the-ground situation should be integrally involved. When the appropriate needs and resources align, AMCs, especially those with long-term relationships, can have a significant and positive impact on international humanitarian response.
The authors would like to acknowledge the brave work of their Liberian colleagues who worked on the front lines of the Ebola epidemic to deliver medical care to those in need. They would also like to acknowledge the faculty from U.S. and African medical schools and teaching hospitals who traveled to Liberia in the midst of an Ebola epidemic to help support relief efforts during this humanitarian crisis. The would like to remember those colleagues lost to the Ebola Virus Disease battle: Dr. Abraham Borbor, Dr. Samuel Brisbane, Dr. John Dada, student–doctor Thomas Scotland, and the Ugandan surgeon Dr. Samuel Muhumuza Mutooro.