onsdag den 11. marts 2015

A retired Uganda Registered Nurse: ‘Six times I fought a war against Ebola – and beat it’

I met Tony Onena in Gulu two weeks ago. Tony just returned from Monrovia in Liberia where he helped combat Ebola as a nurse

Just returned from West Africa in Monrovia City in Liberia, one of the most experienced Ebola nurses in Africa tells his unique story about the numerous hemorrhagic outbreaks in Uganda and West Africa.

He helped to stop and shares his powerful but simple suggestions about global and local preparedness - from a rare practical and comparative perspective. Among his recommendations are:
·       Better selection of health workers.
·       Practical training and better managements.
·       Sharing of experiences.
·       Closer government attention to social practices.
·       Gatherings are essentials…..and early preparation for unexpected hemorrhagic fever that can hit anywhere globally.
Gulu in Northern Uganda February 2015
Tony Walter Onena a 63 years’ old, Retired Registered Nurse served for 34 years and 8 months in Uganda Ministry of Health, before getting mandatory retirement while at Gulu Regional Referral Hospital on January 10, 2012.
Tony Onena from Northern Uganda in Gulu District is probably yet the only health worker I have met to have beaten Ebola 6 times: 5 times in Uganda in 2000, 2007, three outbreaks in 2012 and now he beat it in Monrovia, Liberia in West Africa.
Tony is a strong hearted personality, he doesn’t fear anything: Ebola, jealous colleagues, hospital directors, international researchers or presidents.

Gulu outbreak 2000
When Ebola struck Gulu in Uganda in 2000 Tony didn’t know at first what it was until he attended a funeral in a village close to St. Mary’s Hospital Lacor, where people talked about the disease that would strike and never missed target to kill as majorities who were infected in Gulu died.
The following day when he returned to Gulu Regional Referral Hospital on Monday, October 10, 2000, the Medical Superintendent of Gulu Referral Hospital, Dr. Felix Ocaka Kaducu cancelled annual leaves to all the Nurses and Doctors and requested them to return for work to face the deadly Ebola disease in the medical isolation ward.

Nobody volunteered at the start except Tony Walter Onena, while other colleagues reacted negatively for fear of the deadly Ebola disease. Onena walked together with Dr. Kaducu to face Ebola on the ward. Later, after they left for the highly infectious ward, other volunteers slowly reported in, when WHO and the Ministry of Health organized special payments for lining up pockets.
 One of the first World Health Organization (WHO) experts specially trained to fight Ebola who came to Gulu in Northern Uganda, was Dr. Simon Gardel, whose practical training, immediately caught Tony’s full attention because his practical and simple  training methods made sense in Gulu.
Tony, who practiced Journalism and was working with Vision Group in Uganda, during his free time as a Nurse, secretly recorded WHO expert, Dr. Simon when he was training Gulu Health workers on how to face Ebola disease. He learned all the procedures by heart that enables him to carry out nursing procedures for fighting Ebola.
The Dr. Simon was particularly keen and strictly sticking to simple routines. Tony many times saw how Dr. Simon would loudly and promptly criticize anybody who was sloppy, lazy, dropping injection needles on the ward, or carelessly handling infective patient material, blood or linen. Tony still remembers Dr. Simon saying, “Regard any used injection needle left lying on the ward as an exploded bomb that can kill anybody after accidental prick”.
At the beginning, before the arrival of WHO expert, Dr. Simon, “We had been putting on simple gloves and without proper Protective Personal Equipment, (PPE) and most of us operated under great health risk that lead to many health workers death in Gulu, particularly at St. Mary’s Hospital Lacor.” said Tony.
Dr. Simon, the expert from WHO brought in new ideas of putting on triple gloves, protective suits and basic protective routines of handling patients. Washing hands with chlorine mixtures that kills the virus of the deadly Ebola was a must, before touching and after touching the patient to avoid spread of Ebola infection.  .
Follow the money
Tony was worried about the payment issue, an issue that would come up again and again, also in West Africa, Monrovia - Liberia. The introduction of a special payment for Ebola work tended to attract a type of health workers that were charmed by the extra salary more than they were dedicated to being careful health professionals working in a hazardous environment.
 Tony remembers how their sloppiness out everybody at a risk: needles left in patients beds or on the floor, blood drops left on clothes or unidentified clothes, linen and drip lines left on the floor. It also attracted people that liked to give orders and get a high pay for it and that taught Tony two things: separate management from the clinical team: management should take place outside the clinical setting.
You train the team, go through the routines until everybody is fearless, safe and confident and they should work as a uniform team that does not jeopardize each other’s safety. Some managers tried to interfere and take advantage of Tony’s team but he learned to separate clinical care of Ebola patients from management issues. That, he says, gained him a lot of enemies, but his teams have always beaten Ebola and none of the team members contracted Ebola disease.
Monrovia, Liberia August 2014
Tony, through his good recommendations’ record from Gulu Regional Referral Hospital, to Ugandan Ministry of Health, the World Health Organization, contracted him as Ebola Case Management Consultant alongside other team from Uganda to go and help combat the deadly Ebola disease in Liberia.
When they arrived at night in Monrovia on Friday, August 8, 2014, the following day on
saturday, they were assigned to a very big hospital, John Fredrick Kennedy (JFK) Hospital where MSF had been treating Ebola patients but they shut it down, when some of their health workers had been infected and died of the deadly Ebola.
At JFK Ebola treatment Unit, the bed capacity for Ebola patients was only 35, but shortly after 13 WHO Ebola Case Management consultants team, from Uganda arrived, the rumor must have spread as he said: “They came with three ambulances the first day with 12-15 patients in each Ambulance and by the end of the day, the number of patients were overwhelming the health workers as 70 patients were admitted to a ward with capacity of only 35 bed.
As in Gulu the Ebola extra pay had attracted types of health workers that were no dedicated to combatting Ebola but merely looking at Ebola as a financial Empire. That turned out to become a factor that significantly delayed the Ebola response in Monrovia.
The Liberian health workers were less impressed and went on strike because they claimed their government was a hindrance to the top up money, WHO had planned to pay for the Ebola fighters in Monrovia.
On one day, Liberia Speaker of Parliament, and a Member of Parliament for Mountserrado County came to Island Clinic, Ebola Treatment Unit where Liberian Health workers engaged them in a hot heated argument about their salary.
 That argument about the salary was not so simple and the two parliamentarians invited Liberian President who came to settle the matter before it had exploded in to a maximum strike. When the President arrived, she got the health workers who were angrily charged and wanted the president of Liberia to dress in the Ebola personal protective Equipment, outfit and go the wards to get a feeling of how stressful the job was.
“At one point”, Tony recalls, “I was very worried, because our Liberian colleagues were so frustrated over the lacking salaries that they decided to wrap up one of the Ebola victims dead body, to carry the corpse to the Ministry of Health and dump it there to demonstrate their anger”. They were stopped but only last minute.
Tony explains: “People of Monrovia don’t have gardens to dig, they don’t have their own food, so they have to buy food, and that requires a salary”. Tony is certain that the salary issue seriously delayed the Ebola response and should have been dealt with months before.
Fatal private clinics
An even more worrying, and ignored, consequence of the lacking salary to health workers was that health workers in frustration started to open up their private treatment clinics at home to earn some money for survival. Unfortunately, as they handled patients in their clinics, they became infected though they were trained by Ebola Case Management consultants.
Tony’s gaze becomes distant explaining this; he is almost counting the huge number of cases that must have followed from this disorganized and dangerous practice hidden from authorities and the media. He acknowledges that, the health workers did it for survival that lead to Ebola to infect them.
Tony remarks “Many of these nurses ended up dying from Ebola themselves in their own clinics because they lacked skills and equipment and their training was simply not up to date”. Tony says that one of the experiences he gained during Uganda outbreaks was physical seeing the patient being treated as part of the training in the treatment of Ebola. He said theoretical training is very good but that is not enough for handling the deadly highly infectious disease: “you should learn by doing, not just by listening”.
Forced to focus on treatment
Another factor that Tony keeps mentioning is that practically all health facilities and works were employed with Ebola management. But patients of course kept coming with other acute health problems as diarrhea, malaria, tuberculosis, AIDS or NCDs. These patients were treated as Ebola patients but initially didn’t suffer from it – they contracted it in hospital.
The weak health care system in Liberia forced donors and international aid organisations to focus on treatment and management of cases, while the most important activity: public messages, were given less priority. That was a huge mistake but what else could they do under the circumstances?
Ugandans were good listeners

Comparing the Uganda Ebola response to the situation of West Africa Ebola, Tony has a lot to say. “For one thing, Ugandans are good listeners. If we tell them: don’t shake hands and don’t sit too close in church, forget to grab your lovers for huge on the chest during Ebola period. Ugandans would listen to the health workers.

That wasn’t the case in Liberia where the health massages fell on death ears and Ebola could not be fought for only one month as it had been to many Ebola outbreaks in Uganda. In Uganda church masses were split up into 8-10 church services per day only allowing smaller groups to enter at a time, so that attenders could sit with space between them. Markets were organized better etc.

That was never done in Liberia – there was poor contact between World Health Organization Ugandan teams and the Liberian health authorities for planning to contain Ebola within short time. Had the Liberian Health authorities contacted us to tell them what we did in Uganda during Ebola, we could have shared this kind of information – we felt they either ignored or didn’t want know our past experiences in fighting Ebola”.

The experienced Ebola expert lists his suggestions for future outbreaks, some of them are controversial he admits, but necessary he says:

1.      Better protective gear should be provided. Protective suit should have oxygen and better ventilation so health workers can work for longer periods and not be interrupted by fatigue as often.
2.      Transparent body bags for safe but (more) culturally appropriate funerals.
3.      Cameras should be installed to observe management and for training of new staff. It also serves to minimize physical patient contact while maintaining emotional support.
4.      Money should not be the sole criteria for attracting health workers: they should be carefully selected. Incompetent sloppy health workers put the other team members at a high risk.
5.      Experienced Ebola management teams should always be called in and their experience should be collected and used after careful local adaptation. An international unit should secure that previous experience is made available to local response teams and authorities.
6.      Church services should be organized to minimize physical contact. Public messages about greetings should be in place. Schools and markets should be re-organized to minimize contact.
7.      Issues of salary should be dealt with promptly before they jeopardize safety and delay management.
8.      Fleeing doctors and nurses and abandoned health facilities can be avoided by better training and constant supervision. The three weeks closure of the MSF hospital in Monrovia is likely to have delayed the response.
9.      Morning briefing meetings should be held every day with all stakeholders’ incl. bus services, market place managements, police, religious leaders and school leaders. Normal information systems are not working and many counterproductive rumors can be dealt with at these meetings.
10.   Public messages should be prioritized but it requires that health workers are well trained for emergencies.
11.   This thing (Ebola) can happen anywhere – so prepare for the event, don’t wait for it to happen
12.   Tony believes that there should be scientific intervention in the production of personal protective equipment for fighting Ebola by use of hydrogen peroxide to produce oxygen for the health workers during their services on the ward.  

A strong elephant

Tony observed huge differences in death rates between different hospitals in Monrovia. Every day these data would be published, but nobody seemed to react to them, Tony recalls: “We (the Ugandan team) had very low death rates because we had routines and good training, but the other hospitals did not perform as well”.
Some health workers even became jealous and asked “why don’t the Ugandans contract Ebola, die and go home in a coffin?”  He was proud of the fact that it was their experience from Uganda, and meticulous routines that did the trick – not some kind of magic – and he didn’t bother about the wickedness of the remarks. “I am a strong willed man confident that Uganda routines will combat Ebola”, he concluded.
When Tony finished his 4½ month assignment in Monrovia, Liberia, his Liberian colleagues gave him a walking stick with a handle in the shape of an elephant. You are strong as an elephant they told him. He had confronted administrative mismanagements, fear, jealousy and he beat Ebola for the sixth time.
“I have great optimisms to change Personal Protective Equipment (PPE) that can make Ebola fighters to stay longer than two hours on the Ebola highly infectious ward. If I could be given chances to plan with the medical scientists on what to do, in the manufacture of PPE.
Secondly, use of cameras on Ebola ward can help very much for training health workers on how to fight Ebola. The relatives and journalists who come to Ebola treatment units for news and relative also can be able to see their Ebola patients on ward by tactful means of using such cameras on the ward.” Said Tony.  

Morten Sodemann, below is the correct contacts that can reach me (Tony Walter Onena). I am therefore requesting you for update of my contacts because the one you released has an error. This means that, those who want to contact me will never go through. I hope I will be very grateful if for that correction of the contacts.
 Lastly, I am reminding you if you could organize with the authorities concerned there, to give me a chance to come for one of the health meetings around THE WORLD and I talk to the medical scientists, about improving PPE for longer use on Ebola ward.
For contact to Tony Walter Onena:
 SKYPE: twonena.
PHONE: +256 772 961 615 / +256 794 895 658 / +256 716 961615
For media and other accounts of the 2000 Ebola outbreak and its heavy toll on heroic health workers:

Fighting Ebola in 2000 at Gulu Regional Referral Hospital IN Northern Uganda, where I retired as Senior Registered Nurse, and that time I had already practiced journalism since 1995 while serving under Uganda Ministry of Health.

UGANDA PHONE:+256 772 961 615 
UGANDA PHONE:+256 711 961 615
UGANDA PHONE:+256 794 895 658
 LIBERIA PHONE:+231 880 034 193
SKYPE: twonena.

Photo: Tony shakes hands with President Museveni (Photo: Tony Onena)

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