It was around this time, in late September, that Dr Nkeshimana checked his phone during a meeting and saw 10 missed calls. Now head of the department of health workforce development at the Rwandan Ministry of Health, he previously led the emergency department at the University Hospital of Kigali, and was designated a first responder in an infectious disease outbreak.
“When I got on the line I already knew it must be serious. I said, what kind of disease are you talking about? Is it Ebola? [My colleague said] ‘no, it’s number two on the list’,” recounts Dr Nkeshimana. “The call was in the morning, and he said to be ready by 1pm, because that’s when I’ll give you patient number one.”
For the next few hours, Dr Nkeshimana was rapidly phoning through the list of trained 24-hour responders, who had taken part in pandemic simulations in preparation for this eventuality.
“Actually, as expected, some of them were very afraid and were not willing to join,” he says. But enough were; by 1pm, they had assembled at the new treatment centre, while their colleagues “hijacked” a nearby hotel that became their isolated base, to prevent them taking any infection home.
“It was very, very, very, very scary,” says Dr Nkeshimana. “When we reached the treatment facility to go to the patient area… there was another obstacle to pass: who was going inside first? You could see people trembling. They have the knowledge, the experience, they are the best in this area. But they are already trembling, we were all scared.”
The first week was the worst. “It was very, very, very deadly because the people had an advanced stage of disease, and the team were getting used to the working environment, getting beyond their fears,” Dr Nkeshimana says, adding that the majority of the 15 people who lost their lives died that week.
‘What if I did something wrong?’
Treating Marburg is no mean feat, and not just because there are no specifically approved treatments or vaccines. Patients in the clinical, white health facility were suffering from severe vomiting, diarrhoea, and fevers as high as 42 degrees. As their conditions deteriorated, they bled heavily.
Meanwhile the doctors and nurses responding – who nearly all already knew at least one patient by name – were donned head to toe in critical, but hot and cumbersome, personal protective equipment (PPE).
“We had massive sweats. You would cope with probably two hours in PPE, then we’d carefully come out of the red zone to go to the green zone, drink water, and let someone else take over,” says Dr Nkeshimana. “Every time you came out of the red zone you just kept thinking, what if I did something wrong, for example in the way you removed or put on your clothes, and I got infected?”
The team, who were closely monitored with health and temperature checks, had to follow rigorous infection control regulations on everything from the order they removed their PPE, to where they kept their paperwork. Nor were they able to go home, instead staying at a hotel requisitioned for an “isolated bubble”.