Covid-19: Protecting frontline healthcare workers—what lessons can we learn from Ebola?

On March 23, 2014, the World Health Organization (WHO) announced an outbreak of Ebola in West Africa. The virus, which originated in Guinea, subsequently spread to neighbouring countries and become the largest Ebola outbreak in history. As the health system became inundated with patients, the resources needed to protect healthcare workers from infection became increasingly scarce. By the end of the outbreak, over 50% of infected healthcare workers died and, of those that survived, countless were left with post traumatic stress disorder. Healthcare workers became martyrs; but the repercussions for patients and providers were catastrophic.  

Marine-grade vinyl, industrial tape, cotton, foam and elastic. These sound like supplies for a 5th grade science project, but they are materials that the U.S healthcare workforce are using to make their own personal protective equipment (PPE). When the U.S Centers for Disease Control and Prevention recently recommended that bandanas and scarves be used as a last resort in the absence PPE, photos of healthcare workers sewing their own facemasks soon went viral, alongside the hashtag #GetMePPE. The images are striking: the minute attention to detail required to sew is powerfully illuminating a stark realityproviders’ lives are literally in their own hands. 

We know that two of the most effective ways to protect the healthcare workforce from infectious disease is through diagnostic testing and adequate PPE. Yet as the covid-19 pandemic spreads, shortages of both have been widely reported. The impact? As of mid-March, over 3000 healthcare workers in China have been infected; healthcare workers may account for as many as 8.3% of cases in Italy; and the United States recently reported its first physician death.

In the midst of an epidemic or pandemic, healthcare workers are at the frontline. And when the frontline becomes incapacitated, the health system disintegrates. During the Ebola 2014-16 outbreak in West Africa, this is exactly what happened. The impact, both short term and long, was catastrophic. 

In 2015, the World Health Organization (WHO) published a report stating that certain healthcare workers were up to 32 times more likely to become infected with Ebola than the general population. As the outbreak progressed, healthcare worker infection rates would range from 2.1% to as high as 50%. The disease was no less virulent in facilities with low healthcare worker infection; what differed was facility preparedness. What does this tell us? That health provider infection and death are largely preventable. It doesn’t matter if you are in Sierra Leone battling Ebola, or the United Kingdom responding to covid-19—healthcare workers can avoid infection if properly protected

High rates of infection during Ebola were largely driven by insufficient or incorrect use of PPE, in addition to contact with unrecognized infected patients. Similar to COVID-19, many Ebola cases presented as nonspecific. Symptoms—such as fever, fatigue, and diarrhoea—mirrored those of more common diseases in West Africa, such as typhoid fever and malaria. Contradictory isolation and treatment strategies dependent on diagnosis created a conundrum for providers—a short supply of PPE meant it had to be used sparingly; but a lack of diagnostics meant there was little basis to know who had Ebola. As a result, providers risked contracting the disease as they tried to treat patients who were ill, but not yet diagnosed. Infections of HCWs and the subsequent nosocomial infection of patients, resulted in hospitals being stigmatized as “incubators of infection,” which deterred patients from seeking necessary care and further exacerbated spread

Descriptions of how the Ebola outbreak unfolded sound eerily familiar to those of covid-19. A shortage of essential supplies has already been widely reported and, without intervention, will only escalate as cases rise. Doctors report increased anxiety, fearing they will not only expose themselves to the virus, but also their families and their communities. “We are at war with no ammo,” a surgeon said in a recent New York Times article, referencing the lack of access to basic surgical masks, with existing supplies quickly diminishing. Compared to West African countries faced with Ebola, high-income countries have stronger health systems and significantly more resources. Yet despite these clear advantages, the failure to take action and protect the healthcare workforce has surprising parallels. 

While efforts are currently underway to address supply shortages, the speed at which countries are moving will determine how many lives are lost. For example, the U.S.’s next order of respirators could take up to 18 months to arrive. Consequently, pressure is being put on the providers themselves to secure essential materials, an approach that is not practical or sustainable. While the private and non-profit sectors are stepping up innovative efforts, the increased manufacturing of critical supplies requires centralized leadership, through mechanisms like executive order

As we push for more supplies, it is important to remember that healthcare workforce protection isn’t limited to physical health. While caring for patients is deeply challenging in its own right, other factors, such as witnessing the loss of those within one’s immediate circle, including colleagues, can result in significant psychological trauma. During Ebola, the acute clinical demand often forced providers to carry on; deferring grief until later. To this day, many of the healthcare workers that worked with Ebola patients continue to experience PTSD; a well-established risk for providers in outbreaks. As stated by the WHO, mental health sequelae of epidemics often constitute “an emergency within an emergency” in their own right

Healthcare worker burnout has already been widely reported. Burnout is associated with a suite of negative outcomes in addition to workforce departure: provider depression; reduced quality of patient care; interpersonal conflict, among others. In the midst of a pandemic, we simply cannot afford this; we need to invest in the resilience of healthcare workers. 

For covid-19, steps have already been taken that could reduce burnout: telehealth services have been upped and financial barriers to accessing them reduced, some scope-of-practice laws have been relaxed and non-profit organizations have compiled publicly available guidelines on how to mobilize community health worker (CHW) responses. These efforts align with strategies that were effective during Ebola. Non-clinical CHWs were critical to reducing viral spread through contact tracing and community education campaigns in densely packed slums. This kind of task sharing allows healthcare workers to focus on work that they are uniquely trained for, while leveraging trusted members of the community

The West African Ebola epidemic had severe physical and mental health consequences for healthcare workers, and as a result, the larger community. The fact that most healthcare workers deaths could have been prevented with simple interventions—diagnostic testing, proper equipment and training—makes their loss especially devastating. Given that the covid-19 pandemic is just beginning, the reports of healthcare worker infections are alarming. Ebola and other epidemics have already shown us the consequences of not protecting HCWs. We don’t need another set of ‘lessons learned.’ We know what needs to be done. To fail to act is not only an act of negligence; it is blood on our hands.

Megan B Diamond is an Assistant Director at the Harvard Global Health Institute.

Liana Woskie is a Research Fellow at the Harvard Global Health Institute and a PhD Candidate in Health Policy at the London School of Economics.

No competing interests declared.