An interview with Ebola survivor and frontline responder Dr. Rick Sacra
Dr. Rick Sacra: My first time in Liberia was in 1987-88 for about ten months as a medical student and finished my training and did a residency in family medicine; finished that in 1992. East Tennessee State University - the program I was in was located in Bristol. Bristol is the very north east corner. There is a little part of Bristol that touches Virginia. Bristol, Tennessee State and Bristol, Virginia. The main street, it’s on the state line. When you cross the street you’re crossing from Tennessee into Virginia.
We went to back to the University of Massachusetts; I had a debt to pay in UMass. I had to serve in Mass. for a while and work in Mass. to take care of my obligations to the state. Then we joined SIM, the mission, the same one we had been on here when we came in 87. We didn’t choose Liberia or anything. They accepted us for a whole year and the reason they did that is because my wife is a school teacher. They needed Debbie, my wife. At that time they had a missionary school here. With SIM, you raise funds to support yourself. It’s an organization where the missionaries go out to churches and individuals willing to give a certain amount of money per month for a church. We have donors that give every month – $65,000 or $70,000 a year to support us as missionaries. That’s transportation, social security, housing, living expenses.
UNMEER: So you contracted Ebola, went back to the U.S. and now you’re back?
We were here from 1995 – 2010 then I had kids in high school, one in college and one in junior. We had reached the end of what we did here.
We went home for a while. We actually took a break from the ministry. I went to work at a clinic in Worster. Last year, I was here in February, I was here in May, I was due to come back in the middle of August then Dr. Brantly and Nancy Raipaul got sick and had to get evacuated. And SIM asked me to move up my trip by a couple weeks and come on in to make sure that there was adequate help for them.
UNMEER: When you were here in 2013 and before, were you working at this hospital?
I’ve always worked here at ELWA, I’m a family doc. We do everything. We take care of kids, we deliver babies we do C-sections, we take of high blood pressure and heart disease, malaria, TB, AIDS and all that. A whole range of things.
So they asked me to come down a little earlier. So I got here August 4th. When I got here on August 4th all the hospitals in Monrovia were closed, completely shut down. First, there was the Ebola problem where you had people dying on the street, outside Ebola treatment units, waiting to get a bed. And then they were trying to build the MSF unit out here. Then, there was community push back first where they didn’t want it. That was really awful. That delayed things and that was really awful. The first two weeks of August we were the only unit in Monrovia because they hadn’t opened this other one yet.
ELWA 2 is very close to the hospital entrance. It was originally 40-bed capacity and now it’s up to 60 beds, because the Germans added some more capacity to it. But they’ve had as many as 80 people in there. They’ve squeezed them in. ELWA 3 is the one MSF built, the big tent city down here with 240-bed capacity.
So first, there was that problem and then there was the problem that all the hospitals were closed. So we had woman in labor, who had obstructed labor who had nothing to do, nowhere to go. That first week we delivered 15 babies in the first week of August. Thirteen of them had already died inside before their mothers even arrived here at our hospital. One of the women I took care of, probably the worst one probably from the standpoint of just how horrible the situation was, had been in labor for ten days. And she had been at a clinic and they thought they could deliver her. The head was down pretty low and they had actually cut an episiotomy two days before she got here. There was infection and bleeding, I mean these women were really sick, they were in septic shock and this kind of thing.
As you can imagine, dealing with such patients, it was kind of difficult to figure out, well gosh, could these women who had been in labor for a week, and you know a lot of them have fevers, but could one of them actually have Ebola? At that time, there was no lab here. At that time, we had to send samples all the way down to the airport to the national lab and it was sometimes three or four days before we got results. It was always at least a day and a half and it was often three or four days before we got results. You couldn’t really use that to help you in decision-making about what to do with a certain patient. So the third week in August, we had several pregnant women. Three who died in the same week. One of them I know had HIV. When we did the screening, she had HIV. She may have also been the one who had Ebola, she made have had both.
UNMEER: These women coming in to you to be treated – what are the procedures for treatment?
We’d have a conversation out at the gate, take the temperature with a touch-free thermometer, a scan temperature, and then if we decide okay we’re going to take you inside, we’d put on a gown, and gloves, a mask. For these labor patients, we usually wear pretty full not the total full tile suit thing. But a plastic gown with gloves, a mask, goggles or glasses and rubber boots, so that is sort of our standing working-on-the-floor uniform. If you have a surgery to do, you’d wear basically that same thing, plus a surgical gown over that.
There were a couple of things we were not doing that we are doing now partly because I got sick. One is that we now have sprayers in the hospital. We used to only use the sprayers in the ETU. We didn’t have people with the bleach. We said that if we had an Ebola case we’d call sprayers over from the ETU. But there were so many people you didn’t know. You couldn’t get a timely test and you couldn’t send these women to the ETU – well the they didn’t have beds half the time. There were so many constraints and difficulties at the time.
UNMEER: The sprayers had chlorine?
A sprayer, an individual, that’s their job. They have the spray can on their back with the pump and the bleach. So that way if you had a sprayer, if you had a patient who’s bleeding on the way to the bathroom, you can come in and get sprayed all down. And when you’re done doing a delivery or doing a surgery you can get sprayed down first before you take everything off you and get decontaminated first. A lot of us think that the riskiest time is actually when you’re getting out of your PPE/getting out of your surgical stuff. If you haven’t decontaminated its risky because you’ve got all that blood and fluid all over yourself and you’re trying to get out of it. When you take your last glove off you’ve got your hand and then you’re taking your last glove off the other hand - what if there’s fluid on it? It’s just tricky to do it. So that’s an added protection. So now when we finish surgery we get sprayed down first. So that if there is any blood or fluid on you can be sprayed down with bleach, so that’s an added protection.
UNMEER: Do you think that’s how you contracted it?
The woman I’m thinking of, she was confused - the one who had HIV - who was confused. We had to hold her and restrain her to get her I.V. started and to get the full catheter in the bladder. And she was doing a lot of moving. So it was either during that process of getting her ready for surgery or after the surgery. I’m just thankful that nobody else got sick.
UNMEER: She was a confirmed case?
No, no, no. See, I don’t know, I’m just suspecting. We had three women the same week who died. Heavy bleeding, term pregnancy, that were bleeding so much. You could save their lives by doing a C-section. You can control hemorrhage by doing a C-section. We were trying to save their lives. One of these women did have Ebola. We didn’t know. One of them got tested. One of them lived longer, like two days, and we tested her before she died. She was negative.
UNMEER: What was it like to have Ebola?
It was a Friday night I had been feeling a little off during the day but. I didn’t think anything of it. I thought I was just tired or something. Then in the evening around 10pm I had a chill and knew I was getting a fever. I took a temperature. I had a 100.8 degrees Fahrenheit. It’s not high but high enough to let me know I had a fever. From that moment, I isolated myself and I didn’t leave the apartment where I was staying. I started checking my temperature basically every hour or two. I didn’t have any other symptoms that whole weekend - that was a Friday evening. All day Saturday, all day Sunday - I didn’t really have any other symptoms, maybe a slight headache, mild nausea; mild symptoms. I was on the phone with my wife talking about it. I told her that I thought I probably had Ebola because I really felt like this was different than anything I have had because normally when you have a fever, with Malaria or other things, you’ll spike a temp and then it will break. And you’ll feel chilly, you’ll get a temp and then you’ll sweat, then it will break. Then it will wait a few hours and you’ll have another temp. Like when you get a virus it kind of goes up and down. This one was just up. It just stayed there. Mine didn’t get that high. I never broke the whole weekend I had a temperature. Both nights did take Tylenol, one or two nights when I went to bed to help me sleep. It made me feel a little better so I could rest.
I was really praying a lot, hoping I didn’t have Ebola but just praying, trying to trust God for what would ever might come. Mainly I was really worried about my wife and kids and what this would put them through if I really had Ebola. And what would happen to the hospital. Cause every time someone got sick, they’d close the hospital to decontaminate it. Half the staff would say I’ve got to stay home for 21 days and make sure that they’re not sick. I knew that I hadn’t been ill in the hospital.
I talked with Dr. Brown, he’s a Liberian. He’s really terrific. He told me that if we had a fever on Monday morning and they would do the Ebola test. They came to my house near the beach and they came and did my sample and then they left. By that time, the CDC had open a mobile lab near the ETU. By the end of August we could get the results. I think its seven days a week that they run.
I didn’t get my results til almost six in the evening. Dr. Brown called me and he said, “Dr. Sacra, the results are not in your favor. Unfortunately, your tests were positive.” We had already talked that if I was positive I would go to the treatment unit, we had already discussed that over the weekend. So they started making space for me that was a little bit of a challenge because the place was really full. They had to move some people around. They said I could come Monday evening. And that’s the time I started feeling sicker, started having more nausea, more diarrhea, more vomiting – started feeling weaker. Some people have had terrible pain with it. I heard people say I felt like this, I felt like that. Some people had terrible pain with it - horrible headaches with it; really terrible pain. I did not have a lot of pain. I had some achy muscles - nothing more than a normal virus would do, it’s just that it lasted longer, was more severe. For me, it wasn’t a different category then having a bad stomach bug. When you have a bad stomach bug, you have it for 24 hours and then it’s gone. But this kept going and going.
UNMEER: At what point did you decided you needed to go back to the US?
Actually by that time, because they had the first two evacuated, the CDC knew who I was, and when the result came out positive, I think they contacted the State Department directly. So by the time on Tuesday when SIM was getting ready to call the State Department about the evacuation plan, the State Department had already called first and said we got the plane, sort out the paperwork and get going. So it came as an offer from them before SIM made the request. That was amazing. That was amazing. I was in my apartment for three days waiting to see what was going to happen, then in ETU for three days, on day six which was Thursday, I got flown out.
UNMEER: What was care like in the treatment centre?
Basically it was mainly I.V. fluids. I was given some medications like Tylenol selenium, it’s just a mineral.
UNMEER: What about food?
I was drinking the rehydration stuff. By the time I was in the ETU, I had very little interest in food. I mean, I tried to eat rice a couple of times. I would eat bread snd soak it in water to make it soft and eat it. They did bring around rice and soup. In Liberia, they eat rice and soup. I didn’t have much appetite. I would just kind of eat the rice. Sometimes I’d try. It was interesting. Even though the fever was pretty constant. When I was sicker Tuesday, Wednesday, Thursday, I’d had times I was pretty good and felt okay and could talk to somebody and other times I was like get out of here, leave me alone. I can’t even, I just feel horrible.
UNMEER: They evacuated you to the U.S. and you went where?
They took me to Nebraska. And that decision was made by the State Department. Nobody asked me where do you want to go and nobody asked my family. It was just, “Rick is going to Nebraska.” There are four units, and these were started in the mid-2000s, that are equipped to handle level-four pathogens. So there’s one in Atlanta, it’s associated with the CDC, there’s one in Maryland that’s associated with the National Institute of Health, there’s one in Nebraska, it’s been open since 2005. That was in response both to 9/11 and the concern about bio-terrorism, and then also the SAARS epidemic in 2003. And this was partly in response to that because they were concerned about handling those kinds of pathogens. And then there’s one in Montana that’s associated with the level-four lab. That’s just a small one-bed unit that’s there in case a lab tech got exposed. But they don’t use that one, but they use the other three, the NIH, Atlanta and Nebraska. I think they sent me to Nebraska because they wanted to make sure that all the units were utilized. Cause you learn as you do the work, you learn and get better at it to spread it out. They knew that they would need more capacity. To get as many people up on it would be better.
UNMEER: How did you make the decision to come back to Liberia?
I don’t think that was a question for me. This is my adoptive home; my second home. Obviously the needs are incredible. The doctors told me that I would be immune to Ebola. So that is kind of a relief. Not to have that hanging over my head. Even when I left Nebraska they asked me if I would go back. I said, “Yes, I would go back.” I don’t think I thought about not going back.
UNMEER: Is there stigma associated Ebola when people know you’ve had it?
You know it’s interesting, personally I received very little stigma. Of course people recognized me from the news. As early as the first week of November or even before then, at the end of October I flew somewhere. I was able to fly; people would make me out, make a little face but they got over it. In November I flew to Louisville. I experienced remarkably little stigma. There was a situation. Somebody wanted to come see us and they were in their late fifties and they had grandchildren and their kids told them, “If you want to go and see Rick you won’t be able to go see your grandchildren for 21 days because we want to watch you.” But that happened.
We’d go out. I drove to a restaurant. My neighbors were nice, shook my hand. People were very…it’s interesting in the U.S., now I know there is probably more stigma that really impacts people here than there is in the U.S. There is more stigma, there’s more: “You’re not welcome is this community, or you’re not welcome in this house” here than in the U.S. There are the anonymous comments and news pieces that people leave on the Internet, which people would say because nobody knows who you are and they wouldn’t say it to your face.
UNMEER: What types of comments?
Horrible stuff. “If they want to get Ebola that’s fine they can stay there and die.” Donald Trump said that. Then there’s the stuff the media said. I think the media in the U.S. hyped it a lot. They were talking about Amber Vincent who was on the plane, she probably infected all the passengers on the plane. I heard news anchors saying this on TV. They’re just cranking up the hysteria whereas very few people would say that kind of stuff to me personally. I think the media made it more. Then when I ask people later I said, well how many people got sick on the plane? I didn’t get any answer to that. The answer is nobody.
UNMEER: Some of those comments, how did you feel about that?
Oh, it feels horrible. It was terrible. And then the more responsible media outlets would go out on the street and interview 10 people. Nine out of ten, most people were really positive, especially about the work we were doing, you know some were not happy. Overall, personally I received very little negative feedback or stigma.
UNMEER: One of the things that is a huge issue is this issue of stigma and how it impacts people’s lives, their jobs, their communities, their normal life. What do you think is the significance of – you got Ebola, you recovered, you’re now immune from the virus. What do you think is the significance of this for Liberians?
This is not the first time I started back at work in Mid-November, I started working in mid-November in a clinic I work at in the US, in Massachusetts. And, was allowed to see patients about six weeks out from my hospitalization.
UNMEER: What was that like? What was the reaction of your patients?
Again it was good. I did not have a lot of negative experiences there. I was mainly supervising residents. They were treating patients I would come at the end of the visit and make sure everything was okay. I really didn’t get a negative reaction there.
UNMEER: Do you think that if you had direct contact with your patients from the time you came to the time you left, do you think that you would have had a different experience?
I think among the group that I am around and that I’m dealing with, I think that there would be a few that out of ten, there would be one who would be really bothered but there’d be none who were all fine. The doctors were fine; most of the patients that I was caring for, they were fine. Some of them recognized me, they said, “Oh, we saw you on the news, thank God you are alright.”
I guess what I would say is first of all, we have to let the facts guide our behavior, guide what we do. Yes there’s fear, there’s emotion. But we have to let the facts guide what we do. The fact is that once someone has recovered from Ebola, we don’t send someone home the moment they look okay. We keep them in the unit for several days. I was in Nebraska for six days with no fever, feeling good in Nebraska. They tested me and they waited and tested me and they waited and tested me again. Here, everyone has to have two blood tests that are negative, no fever, no symptoms. And two negative blood tests before they can go home. It’s really important that people realize that that person is not able to spread Ebola. Now there’s one exception that men can carry the virus in the sperm in the semen for up to three months is our understanding. So men have to either stay away from sex or use condoms, use protection and be very careful on how they clean up afterwards in terms of soaking that condom in bleach and washing themselves carefully afterwards. The sexual part, that’s different, but as far as routine contact sitting together at the office, going to school together, eating together in cook shop or whatever. There’s no chance that a person’s who’s recovered from Ebola, they’ve recovered. In fact, the person who’s recovered from Ebola is actually the safest person you can spend time with because not only are they better and have they been tested twice, but they’re immune. They cannot come down with it, they’re safer, they’re actually safer than a normal person to be around.
UNMEER: What is the solution to the stigma problem here?
Some people are able to make it to be around as someone who’s been a survivor. We have a nurse here at ELWA who was working here and became infected. She’s back at work now. She’s here. She’s interacting with all the rest of the staff. Every day, every time she comes to work and she’s treating patients.
UNMEER: What about her community?
She’s got some stigma in there, the community, from what she’s told me. I just got back to the country a few days ago, so I haven’t sat down and asked her lots of questions but I know there was some. But most of her friends are people I know and are very excited about her recovery and are willing to be around her and socialize with her. I think it’s really important for communities that have made the leap of faith, if you will, to get over their fear and to associate with those people. It’s important for those communities to come out and talk about it, what it’s like being around your friends who had Ebola. There’s nothing like personal testimonies of these things to make it real. I think those communities who have successfully re-integrated somebody, a survivor or family of survivors, they need to talk about it and let them know what it’s like, that yes, that person is the same old person, they’re our friend, they’ve been back in our community for two months or three months or whatever and nobody’s getting sick. That’s what’s going to convince people is not a scientist showing an electron microscope or the statistics. It’s the stories of real people I can tell you I have been living at home with my wife and my kids, taking walks shaking hands cause in America, we still shake hands with thousands of people. Since I got out of the hospital, nobody’s gotten sick. I in fact feel that many people admire me for surviving Ebola and I think we should admire the people here in Liberia who’ve survived Ebola. To me they are heroes. They’ve shown the toughness and the character to get through this thing. I think we need to applaud them and welcome them and accept them and treat them normally. Give them kudos and also treat them normally and let them part of our communities like they were before.
UNMEER: Now there’s a lot of discussion about where we need to go from here, once we get to zero. What is your assessment to make Liberia’s health system better than pre-Ebola?
First of all, for these next few months while we’re trying to get to zero, we need to recognize a couple of things. One is that as long as there’s Ebola in West Africa we can’t really relax. And say, even if Liberia has no cases for 42 days, in a technical sense we can then say Liberia is free of Ebola, but as long as there are cases in Sierra Leone and Guinea, we can’t sort of relax and say we’re okay now. We all know that that those borders are very - families live on both sides of the borders - that people cross the borders freely in both directions in Sierra Leone and Guinea, that people have cousins and brothers on both sides of the borders. We just have to recognize that until West Africa is free of Ebola, we cannot rest and say, “We’re good.” Of course I want Liberia to be free of Ebola, and I’ve very thankful that Liberia has made so much progress. Back in August and September, we were hearing these doomsday predictions. The way it’s turned out is actually that Liberia has done the best. Liberia’s rates are now lower than Guinea or Sierra Leone and has made really tremendous progress.
One thing we all have to be ready for too is that now with so few real cases of Ebola we have to be extra vigilant, because it would be easy to let our guards down and start saying oh it’s just malaria or its probably just this, and we could wind up with a second outbreak or little outbreaks in different places and if we want to avoid that then we have to be willing. People have to be willing if you come down with a fever and other symptoms that are similar to Ebola, even though you may think this is not Ebola, you may have to be willing to go into isolation for a few days and get your Ebola test done to make sure. We used to be in a situation where half of the people in the suspect ward got to be confirmed and were real Ebola cases and half of them were not Ebola and went home. Now we have a situation where 90 percent of the suspect cases or 95 percent of the suspect cases are going to be actually negative. And only one out of 20 may be a confirmed case. And that’s going to make people feel bad. Why do they have to throw us all in there in the isolation ward for three days waiting for a test. But we have to do it because we have to find those few cases, and keep them, care for them the best we can, give them the best chance at survival, but also to have them out of their communities so that it doesn’t cause an outbreak. We have to do that. We all have be ready to make that sacrifice of, okay I will go in the unit, I’ll lay down there for three days, it doesn’t feel good, it feels terrible, but we have be ready to do it for the sake of broader picture our families, our communities and Liberia as a whole.
Now, as to your second question about what’s next. We’ve lost some of our most of experienced nurses, we’ve lost some of our most experienced doctors. We really need to focus on training. There are medical students, there are young doctors who are – I really hope we can focus on training – we need to work on getting the medical school back open again. If new faculty have to come in to play that role – what an impact. You know a doctor can come in, sure treat patients but if a doctor can come in and treat the next generation of doctors that’s having an impact.
So I feel training is the key. Training is the key. Yes, getting the institutions re-open. Still, here in Monrovia our hospitals are not fully open. Most of them are functioning, at least some of the departments are open but they’re not fully open. Right now you have about 400 patients sick out there, but they’re trying to squeeze into a few beds and get cared for in a few facilities. Our hospital is packed. Right now we are having to turn away people because all the beds are full.
UNMEER: How many beds do you have?
It’s small. Right now we are operating with about 50 beds. We have space on OB but we can’t put a male with an acute abdomen on the obstetrics ward.
UNMEER: One of the things that struck me when we talked on the phone is that you felt like working in a general hospital is more dangerous than working in an ETU?
People come in. We had a lady come in yesterday and she was sick for a while, several months. But you wonder what if. So we don’t think this is Ebola because if someone has been sick for several months. But you think to yourself what if she’s had contact with Ebola recently?
UNMEER: What do you do?
When we have a case that we are concerned about we put them in a private or isolated room. We have several spaces in the hospital where we can keep patients by themselves. We don’t enter that room without gear on. When we come out we bleach, when we come out of that room, and we do an Ebola test. Thank God we have testing facilities here. That helps a lot. So we’re able to rule it out by the next day and then proceed. We had a pregnant woman come with bleeding in the first trimester, she had been sick for about a week with fevers off and on. You don’t know so we had to rule her out.
UNMEER: Do you find there’s fear among the medical staff?
Oh sure. That fear is protective to some extent. As long as it leads you to do the right things. We don’t want to send people away and say, “We are afraid of you, you might have Ebola go away.” But we want to say, “You have some symptoms, so we’re going to either, we’ll send you to the Ebola unit on the suspect side and let it be ruled out and let you take a test, and or we will admit you to our hospital and you’re going to be in an isolated room by yourself and treat you with precautions until we get that Ebola test negative.”
UNMEER: You talk about the reopening of hospitals – are there things you like to see done that were not done pre-Ebola?
I don’t have enough knowledge on what was present in other facilities. I am not on the Ministry of Health’s inspection team. I can’t comment about pre-Ebola conditions. But there are certain changes we have to make. At any point where people can enter the facility we have to have triage going on checking temperature, taking history. That has to be done at the entrance. We used to let people walk in a go in and then finally they’d see a nurse or they’d see somebody way inside somewhere. Now we’re doing that at the gate. That’s being done everywhere. Every place has to have resources, all the gear they need when they have a patient, that’s needed. We are not able to reopen fully right away. For the first six or eight weeks all we did was maternity care. Then, we started admitting a few other patients at the hospital, and then we started seeing some adults in the clinic not kids at the beginning, then we started seeing kids. We’ve gradually done things one step at a time. We still don’t have a 24 hour emergency room, that is the highest risk area. And, frankly we don’t have enough staff right now. We’ve had to pull staff out of normal jobs, to become hygienists, to become the spray teams. We now we have nurses who used to be our ER nurses - there, they’re running triage. So we don’t have an Emergency Room right now. We would have to hire additional staff to open all the areas we used to have, we would have to hire additional staff. And frankly right now, we don’t have enough funds to do that. We’ve got almost everything operating but we don’t have an Emergency Room right now. We triage patients at night if they come to the gate to see if they need admission or not. But we don’t do routine treatment at night anymore. We only deal with critical ill people and if they weren’t critically ill, we ask them to come back the next day.
UNMEER: You’ve had a very unique experience. What are your lessons learned, takeaways from Ebola?
I am humbled by the whole thing. I am a doctor - I am supposed to know what procedures to take, what steps to follow. Even though that’s humbling to feel that wow, even trying to do all the things I was supposed to do, it didn’t work and here I got sick. The other humbling thing was having as many people praying for you as prayed for me. God was right there with me and was very faithful in taking care of me. I know I could have easily died. For whatever reason, he has his reasons I was allowed to survive.
And I think that the other thing I really learned is something I knew before but learned in new ways. We all have to be flexible in this kind of situation. We all have to be ready to make changes. NGOs in the world would look at Liberia and how the numbers were going up and they wanted to put all of their resources in Liberia. Then Liberia got better and Sierra Leone got worse. They wanted to go with the plan. We all have to be ready to quick adjustments. Some groups struggled with that. But I think the importance of training is the other take away that we need. You don’t want Liberia to always be in a situation where we can’t handle a crisis. We have to have a health system that has enough staff. Adequately trained people, nurses, doctors. We have to figure out how to make that happen, whatever that is. I know that one of the reasons the health system was so weak was because of the war. Absolutely, we have to take the steps to get beyond the where we were before Ebola. We are now vulnerable to another Ebola outbreak. It’s been popping up every so often, in Uganda, or Congo or Gabon. Some of these places have had two or three or four outbreaks. We could have another one. We could have some other thing. We have to be vigilant and ready and be more prepared.
UNMEER: Thank You.