Ryan Boyko, a Ph.D. student at the Yale School of Public Health, traveled to Liberia in mid-September with a fellow doctoral student at the invitation of the government to help its response to the Ebola epidemic that was spreading rapidly. Although Boyko took numerous precautions during his visit, his return home was marked by a brief scare that he might have contracted the disease (he didn’t) and then a mandatory quarantine in his apartment (about which he has been critical). The experience in Liberia and afterward was intense and eye-opening, says the 30-year-old scientist, who works in Yale’s Center for Infectious Disease Modeling and Analysis (directed by Alison Galvani). Despite some unexpected turns, Boyko remains a strong believer in public health professionals responding to crises such as Ebola and, when possible, traveling to where the need is.
Why did you go to Liberia?
The Liberian Ministry of Health and Social Welfare invited me to come and apply my skills. It was exciting to think that I could have a direct impact on a burgeoning epidemic instead of just analyzing it from afar.
Even though there was an element of risk involved?
There is risk involved in any international work, especially in places with substandard health care sectors. Given the nature of the work in Liberia and the fact we weren’t working directly with Ebola patients, I honestly didn’t feel like the risk was substantially higher than in several other places I’ve been, such as the Democratic Republic of the Congo. That said, we made sure to play it safe and take lots of precautions and to also be very aware of any potential problems like demonstrations and protests.
How long were you there?
Twenty-two days, all in Monrovia.
What safety precautions did you take before leaving and while there?
We brought a lot of Purell and protein bars so we could eat lunches without having to venture out of the Ministry building. We also made contact with the U.S. Embassy, the Centers for Disease Control and Prevention, MedEx, and people I knew from my previous trip to Liberia in 2012 so we would have a solid support network if anything happened. While there, we avoid touching others (e.g., no handshakes), used the hand washing stations in front of all the buildings, used only drivers we knew, and used lots of Purell which we kept with us at all times. We avoided going out and seeing the city or countryside beyond what was necessary for our work.
Describe the work that you did while in Liberia.
We built a community-based system for reporting sicknesses, deaths, and other important events to people at the Ministry of Health and Social Welfare in real time. A network of community leaders had already been identified by Dr. Mosoka Fallah, and we worked with him and Liberian medical students to build an Android app, database, and dashboard that would allow these community leaders to easily upload information about their communities daily so that Dr. Fallah and his team could immediately identify areas needing assistance and then send people there to provide assistance and immediately isolate people with suspected Ebola to prevent further transmission to the community. Among other things, we collected data about the number of people becoming sick or dying, the number going to Ebola Treatment Units (ETUs), the number returning from ETUs — as they often require reintegration assistance — and the number of orphans or others requiring assistance. This way the communities and Ministry can work together, and communities can do something themselves and feel like their government is being responsive to their needs while also hopefully slowing the spread of Ebola.Working with the Ministry, we also created a public website showcasing some of the data the government collects on the epidemic, http://www.liberianhealthresearch.com/index.php.
What were some of the obstacles that you had to overcome?
One of the biggest obstacles was coordinating with all the organizations that were descending upon Liberia in September. Many organizations had just begun or scaled up their responses to the epidemic, and so tasks that needed to be done ran the risk of being done redundantly by people in different organizations. Our partners at the Ministry also were very busy with their own work and coordinating the work of their partners, so we had to balance working quickly with making sure we were providing non-redundant, useful help that met the needs of Liberians.
How can models like you develop stem Ebola?
They can identify effective and cost-effective ways to intervene with the resources already available, such as by identifying geographic areas to focus on; optimal ways to determine resource allocation to individuals, communities, or hospitals; or specific intervention strategies that give the most “bang for the buck” (e.g. the value of better PPE for health care providers versus providing the community with basic PPE [personal protective equipment] versus increasing the number of ETU beds). They can also encourage governments and others to provide more assistance by demonstrating how severe the problem could become without additional funds or other resources. While there’s currently no Ebola vaccine approved for general use, models can identify key populations to vaccinate or intervention thresholds that need to be met (e.g., what percent of the population needs to be vaccinated to prevent an epidemic).
Do you think your contribution is making a difference?
I certainly like to think so. Many organizations have been working to assist the Liberian government with their response to Ebola (EVD), and I think we’re really starting to turn a corner. Sustaining that assistance is key to achieving the eventual elimination of EVD in Liberia. Our work is a small part of that, helping the government be more proactive in their response and empowering communities to connect with the Ministry of Health, strengthening the connections necessary to end the epidemic, and providing for more timely response to new cases, and, therefore, fewer contacts becoming infected. It’s also useful for providing other services to communities, such as assistance with reintegrating into the community after being successfully treated for EVD and providing for Ebola orphans.
How serious is Liberia’s Ebola outbreak?
It’s very serious. Over 150 Liberian health care workers have died of the disease, devastating an already thinly stretched health care system that was just recovering from the effects of civil war. Even after the epidemic ends, this will take many years to overcome. Many people are dying of easily treatable conditions as hospitals have been closed or turned into Ebola Treatment Units and medical personnel are afraid to treat anyone for fear they have EVD.
Describe a typical day.
Breakfast at the hotel, [driven to the] Ministry of Health and Social Welfare across town while listening to radio/talking to driver about EVD and other issues, seeing what is going on in the city. We worked in the Ministry building from about 9 a.m. until about 5:30 p.m., largely on computer code and e-mails, along with a meeting or two. We were then driven back to hotel, ate dinner, worked some more, and then went to bed. It was really not that exciting.
Was there a particularly poignant experience?
At one point we drove by a dead body surrounded by onlookers who were awaiting the body removal team’s arrival on the scene, and the driver had a slow Elton John song, “Sacrifice,” playing. There was something about the combination of a slow, totally ordinary song, the fear and curiosity in the onlookers, and the obvious failure of a health care system that results in a person dying on the sidewalk that was very poignant. It was over two weeks into our trip, so we had gotten a bit used to seeing a body awaiting removal or other obvious manifestations of EVD, and it was the combination of ordinariness, almost banality, and extraordinariness that provoked such strong feelings I think.
What are you doing now?
Still developing the app to be responsive to the changing needs of the users (community members and Dr. Fallah and his team at the Ministry of Health), updating the website, doing some advocacy work to end quarantines and other policies that discourage health care workers from going to West Africa from the United States, doing a bit of Ebola research, and trying to get back into the rest of my research and work as a teaching assistant.
Can you describe the mood of the Liberian people as the epidemic grows?
Fear but also the determination to keep moving and living life as best as possible. There’s also certainly anger at individuals and institutions that people feel let them down, including the Liberian government, donor governments, and international institutions.
It's been a rough few weeks since you returned to New Haven. How did you fill your time during quarantine?
I tried to focus on continuing to work to help Liberia as best as I could, both through the app and website development and through finding ways to influence policy in the United States to encourage, rather than discourage, health care workers to go to West Africa. I also tried to keep up with family, friends and the media and keep a schedule to stay sane.
What's the first thing you did after you were free to leave your apartment?
Went to see my girlfriend.
Will you be returning to Liberia?
I hope so, but I don’t have definite plans yet.
Was going to Liberia during this epidemic the right thing to do?
There are things I would change the next time I do something like this, but overall I think it was the right thing to do.