Executive Perspective Executive Perspective is a regular column in Public Health Reports in which leaders of offices under the Assistant Secretary for Health and agencies of the U.S. Department of Health and Human Services offer their views on public health topics of the day. Dr. Boris D. Lushniak, RADM, U.S. Public Health Service (USPHS), was Acting Surgeon General in fall 2014, when the Commissioned Corps was asked to set up a field hospital in Margibi County, Liberia, just outside of Monrovia to treat Ebola patients who were health-care workers, clinic staff members, or responders. For this issue’s column, I asked Dr. Lushniak to reflect on his role and the work done by USPHS officers at the Monrovia Medical Unit. Frederic E. Shaw, MD, JD Editor in Chief, Public Health Reports
THE HOPE MULTIPLIERS: THE U.S. PUBLIC HEALTH SERVICE IN MONROVIA Boris D. Lushniak, MD, MPH RADM, U.S. Public Health Service
One year ago, in early fall 2014, I sat at my desk in Washington, DC, as the Acting Surgeon General and listened intently to a late evening telephone conference with the leadership of the U.S. Department of Health and Human Services and other leaders of the U.S. Public Health Service (USPHS) Commissioned Corps. Now it was my turn to talk. My words were simple: “It’s a green light.” With those words, I committed the Commissioned Corps to a deployment in Liberia to join in the battle against the growing Ebola epidemic. Our mission was distinct: We were to provide a high level of care to Ebola patients who were health-care providers or staff members from the many Ebola treatment units in Liberia, including both Liberian and international responders. These providers were risking their lives, and we were there to support them if they themselves got sick. But on another level, I realized we were there to raise hope in the people of Liberia and in the responders answering the call for help. I knew it would be one of the most important USPHS missions in modern times. I was confident in the capability, commitment, and professionalism of our officers, but I felt a touch of trepidation as I realized the risks of this terrible disease. We would be the only U.S. government entity providing direct patient care in West Africa. The success of our mission depended not only on our officers, but also on the intricate partnerships that we would have to build with many different entities—the government of Liberia, the U.S. Agency for International Development (USAID), the Department of Defense (DoD), 562
the State Department, and many nongovernmental organizations. As we closed the teleconference that evening, I quietly murmured a prayer for the safety of our officers and the success of the mission. Within a few days, the mission became more real than ever when President Obama mentioned the Corps’ role in his public speeches.1 By October 2014, our advance teams had arrived in Liberia and had begun to cement those crucial intricate partnerships. Soon the hospital, dubbed the USPHS Monrovia Medical Unit (MMU) and built by the DoD, was ready to go. By early November 2014, we were admitting our first Ebola patients. The initial challenges were many, from establishing medical protocols so that we truly provided a high level of care, to securing the chain of vital medical supplies and personal protective equipment through DoD, to assuring that our teams were housed, fed, safe, and secure. Ultimately, the unit was staffed by four teams of 70 volunteer officers, each in two-month deployments (Figure 1). The volunteers came from all across the USPHS and included medical providers, nurses, pharmacists, laboratorians, safety officers, behavioral health providers, and staff members for administration, logistics, and planning. The unit was not meant to be a modern intensive care unit; rather, it offered advanced clinical interventions for Ebola patients, on-site laboratory and diagnostic capabilities, care individualized for each patient, and a high staff-to-patient ratio. I soon learned that the USPHS officers working in the unit were experiencing both the joy of successful treatments and the sadness of losing patients to the Ebola virus. The unit had a survivor wall decorated with handprints of those who had been successfully treated. The motto on the wall read, “Today I am healed, tomorrow I return to heal another (Figure 2).” During November and December 2014, I spoke to many officers as they stopped in Washington on their
Public Health Reports / November–December 2015 / Volume 130
USPHS Response to Ebola in Monrovia 563
Figure 1. U.S. Public Health Service volunteers at the Monrovia Medical Unit in Margibi County, Liberia, March 6, 2015a
a Boris Lushniak (center) poses with volunteer officers at the Monrovia Medical Unit in Liberia, each of whom served in two-month deployments. The USPHS volunteers included medical providers, nurses, pharmacists, laboratorians, safety officers, behavioral health providers, and staff members for administration, logistics, and planning. Photo by Boris D. Lushniak.
Figure 2. Survivor wall at the Monrovia Medical Unit in Margibi County, Liberia, January 30, 2015
A survivor wall decorated with handprints of those who were successfully treated for Ebola brightens up the Monrovia Medical Unit. Photo by Boris D. Lushniak.
Public Health Reports / November–December 2015 / Volume 130
564 Executive Perspective
way home from Monrovia. On Christmas Day 2014, many of them were at my home in Maryland for dinner and a night of reflection and storytelling. I remember feeling so happy that I served in an organization with those fine volunteer officers. But I also felt a longing to go to Monrovia myself. My public health career has been shaped by multiple responses—Bangladesh for natural disasters, Russia for diphtheria, and the United States for the attacks on the World Trade Center, the anthrax attacks of 2001, and Hurricane Katrina. By early January, I was restless to see firsthand how the Corps was performing in Monrovia. I had learned long ago that it is almost impossible to get a true feel for a mission from a desk in Washington. With the arrival of newly appointed Surgeon General Vivek H. Murthy (my new commanding officer) in late December 2014, I got my chance. On January 23, 2015, I arrived in Monrovia, where I was to serve for the next six weeks as part of the USAID team and oversee the MMU.
I soon found my way to the USPHS encampment in Margibi County, just outside of Monrovia (Figure 3). It was named Camp Eason in honor of CAPT John C. Eason, Jr., who in 1943 was the first African American to be commissioned as an officer in the USPHS. As a sanitarian, his assignments included work in Liberia. After he retired in 1974, he continued his public health mission as part of the international health programs of the American Public Health Association.2 He passed away in 2012. Naming the Monrovia camp after CAPT Eason was a truly fitting way to honor this man during our Liberia mission. The camp was in a rural area near the airport and an hour’s drive from the bustle of Monrovia. Soon, I saw for myself that it was a well-organized and fully functional medical unit, consisting of the medical treatment area (including a hot zone for those with confirmed disease) and a separate living and support area filled with military tents for the officers. I was immediately impressed by the can-do attitude of our
Figure 3. Monrovia Medical Unit, U.S. Public Health Service, Margibi County, Liberia, February 9, 2015
Public Health Reports / November–December 2015 / Volume 130
USPHS Response to Ebola in Monrovia 565
officers working in the unit. They were inspirational, whether in the intensity of patient care activities or in the midst of planning and training. I felt inclined right from the start to thank each of them personally for their service. But every time I tried, they lobbed my “thank you” right back at me with a “thank you for selecting me to be here!” From September 2014 to May 2015, more than 300 officers of the MMU provided direct patient care for those with Ebola, malaria, and other illnesses. In addition, they assisted in research protocols, organized educational opportunities for Liberian health workers, and touched the nearby communities. When their care was successful and patients survived, they were joyful. When they lost patients, they mourned. After nine months of work during the worst of the Ebola epidemic in Liberia, the USPHS flag finally was taken down at the MMU on May 1, 2015. Thankfully, the epidemic had waned in Liberia and on May 9, 2015, the nation could claim to be free of Ebola. Since then, sporadic cases of Ebola have been found in Liberia, but the response, in terms of treatment and disease control, is now much more robust. On February 11, 2015, President Obama spoke at the White House about the work of the USPHS in West Africa during the Ebola epidemic: At the Monrovia Medical Unit in Liberia—built by American troops, staffed by (the) team from the U.S. Public Health Service Corps—a nurse’s aide named Rachael Walker went in for treatment and left Ebolafree. And I want you to listen to what Rachael’s sister said about all of you. ‘We were worried at first,’ she said, ‘but when we found out [Rachael] was being transferred to the American Ebola treatment unit, we thanked God first and then we thanked America second
for caring about us.’ And the Americans who she was speaking of aren’t just doctors or nurses, or soldiers or scientists. You’re what one lieutenant commander from the U.S. Public Health Service Corps called the ‘hope multipliers.’3
The USPHS Commissioned Corps and the Office of the Surgeon General were proud to be part of the public health response. Our mission was to assist the Liberian people, and the officers who served there gave of themselves. But I learned long ago that service to others is also service to oneself. As I watched the officers return from Monrovia, from the youngest lieutenant to the most senior flag officer, I could see in their faces the fulfillment that service had brought to each of them personally. Serving the underserved and vulnerable half a world away from home—yes, I think “hope multipliers” is a good way to describe it. Boris D. Lushniak is the former Acting Surgeon General and former Deputy Surgeon General of the U.S. Public Health Service (USPHS). He retired from the USPHS on October 1, 2015. Address correspondence to: Boris D. Lushniak, MD, MPH; e-mail .
REFERENCES 1. The White House (US), Office of the Press Secretary. Remarks from the president on the Ebola outbreak. 2014 Sep 16 [cited 2015 Aug 28]. Available from: URL: https://www.whitehouse.gov /the-press-office/2014/09/16/remarks-president-ebola-outbreak 2. In memoriam. J Environ Health 2012;74:52. Also available from: URL: http://www.readperiodicals.com/201205/2648043231.html [cited 2015 Aug 28]. 3. The White House (US), Office of the Press Secretary. Remarks by the president on America’s leadership in the Ebola fight. 2015 Feb 11 [cited 2015 Aug 28]. Available from: URL: https://www.whitehouse.gov/the-press-office/2015/02/11 /remarks-president-americas-leadership-ebola-fight
Public Health Reports / November–December 2015 / Volume 130
THE HOPE MULTIPLIERS: THE U.S. PUBLIC HEALTH SERVICE IN MONROVIA Boris D. Lushniak, MD, MPH RADM, U.S. Public Health Service
One year ago, in early fall 2014, I sat at my desk in Washington, DC, as the Acting Surgeon General and listened intently to a late evening telephone conference with the leadership of the U.S. Department of Health and Human Services and other leaders of the U.S. Public Health Service (USPHS) Commissioned Corps. Now it was my turn to talk. My words were simple: “It’s a green light.” With those words, I committed the Commissioned Corps to a deployment in Liberia to join in the battle against the growing Ebola epidemic. Our mission was distinct: We were to provide a high level of care to Ebola patients who were health-care providers or staff members from the many Ebola treatment units in Liberia, including both Liberian and international responders. These providers were risking their lives, and we were there to support them if they themselves got sick. But on another level, I realized we were there to raise hope in the people of Liberia and in the responders answering the call for help. I knew it would be one of the most important USPHS missions in modern times. I was confident in the capability, commitment, and professionalism of our officers, but I felt a touch of trepidation as I realized the risks of this terrible disease. We would be the only U.S. government entity providing direct patient care in West Africa. The success of our mission depended not only on our officers, but also on the intricate partnerships that we would have to build with many different entities—the government of Liberia, the U.S. Agency for International Development (USAID), the Department of Defense (DoD), 562
the State Department, and many nongovernmental organizations. As we closed the teleconference that evening, I quietly murmured a prayer for the safety of our officers and the success of the mission. Within a few days, the mission became more real than ever when President Obama mentioned the Corps’ role in his public speeches.1 By October 2014, our advance teams had arrived in Liberia and had begun to cement those crucial intricate partnerships. Soon the hospital, dubbed the USPHS Monrovia Medical Unit (MMU) and built by the DoD, was ready to go. By early November 2014, we were admitting our first Ebola patients. The initial challenges were many, from establishing medical protocols so that we truly provided a high level of care, to securing the chain of vital medical supplies and personal protective equipment through DoD, to assuring that our teams were housed, fed, safe, and secure. Ultimately, the unit was staffed by four teams of 70 volunteer officers, each in two-month deployments (Figure 1). The volunteers came from all across the USPHS and included medical providers, nurses, pharmacists, laboratorians, safety officers, behavioral health providers, and staff members for administration, logistics, and planning. The unit was not meant to be a modern intensive care unit; rather, it offered advanced clinical interventions for Ebola patients, on-site laboratory and diagnostic capabilities, care individualized for each patient, and a high staff-to-patient ratio. I soon learned that the USPHS officers working in the unit were experiencing both the joy of successful treatments and the sadness of losing patients to the Ebola virus. The unit had a survivor wall decorated with handprints of those who had been successfully treated. The motto on the wall read, “Today I am healed, tomorrow I return to heal another (Figure 2).” During November and December 2014, I spoke to many officers as they stopped in Washington on their
Public Health Reports / November–December 2015 / Volume 130
USPHS Response to Ebola in Monrovia 563
Figure 1. U.S. Public Health Service volunteers at the Monrovia Medical Unit in Margibi County, Liberia, March 6, 2015a
a Boris Lushniak (center) poses with volunteer officers at the Monrovia Medical Unit in Liberia, each of whom served in two-month deployments. The USPHS volunteers included medical providers, nurses, pharmacists, laboratorians, safety officers, behavioral health providers, and staff members for administration, logistics, and planning. Photo by Boris D. Lushniak.
Figure 2. Survivor wall at the Monrovia Medical Unit in Margibi County, Liberia, January 30, 2015
A survivor wall decorated with handprints of those who were successfully treated for Ebola brightens up the Monrovia Medical Unit. Photo by Boris D. Lushniak.
Public Health Reports / November–December 2015 / Volume 130
564 Executive Perspective
way home from Monrovia. On Christmas Day 2014, many of them were at my home in Maryland for dinner and a night of reflection and storytelling. I remember feeling so happy that I served in an organization with those fine volunteer officers. But I also felt a longing to go to Monrovia myself. My public health career has been shaped by multiple responses—Bangladesh for natural disasters, Russia for diphtheria, and the United States for the attacks on the World Trade Center, the anthrax attacks of 2001, and Hurricane Katrina. By early January, I was restless to see firsthand how the Corps was performing in Monrovia. I had learned long ago that it is almost impossible to get a true feel for a mission from a desk in Washington. With the arrival of newly appointed Surgeon General Vivek H. Murthy (my new commanding officer) in late December 2014, I got my chance. On January 23, 2015, I arrived in Monrovia, where I was to serve for the next six weeks as part of the USAID team and oversee the MMU.
I soon found my way to the USPHS encampment in Margibi County, just outside of Monrovia (Figure 3). It was named Camp Eason in honor of CAPT John C. Eason, Jr., who in 1943 was the first African American to be commissioned as an officer in the USPHS. As a sanitarian, his assignments included work in Liberia. After he retired in 1974, he continued his public health mission as part of the international health programs of the American Public Health Association.2 He passed away in 2012. Naming the Monrovia camp after CAPT Eason was a truly fitting way to honor this man during our Liberia mission. The camp was in a rural area near the airport and an hour’s drive from the bustle of Monrovia. Soon, I saw for myself that it was a well-organized and fully functional medical unit, consisting of the medical treatment area (including a hot zone for those with confirmed disease) and a separate living and support area filled with military tents for the officers. I was immediately impressed by the can-do attitude of our
Figure 3. Monrovia Medical Unit, U.S. Public Health Service, Margibi County, Liberia, February 9, 2015
Public Health Reports / November–December 2015 / Volume 130
USPHS Response to Ebola in Monrovia 565
officers working in the unit. They were inspirational, whether in the intensity of patient care activities or in the midst of planning and training. I felt inclined right from the start to thank each of them personally for their service. But every time I tried, they lobbed my “thank you” right back at me with a “thank you for selecting me to be here!” From September 2014 to May 2015, more than 300 officers of the MMU provided direct patient care for those with Ebola, malaria, and other illnesses. In addition, they assisted in research protocols, organized educational opportunities for Liberian health workers, and touched the nearby communities. When their care was successful and patients survived, they were joyful. When they lost patients, they mourned. After nine months of work during the worst of the Ebola epidemic in Liberia, the USPHS flag finally was taken down at the MMU on May 1, 2015. Thankfully, the epidemic had waned in Liberia and on May 9, 2015, the nation could claim to be free of Ebola. Since then, sporadic cases of Ebola have been found in Liberia, but the response, in terms of treatment and disease control, is now much more robust. On February 11, 2015, President Obama spoke at the White House about the work of the USPHS in West Africa during the Ebola epidemic: At the Monrovia Medical Unit in Liberia—built by American troops, staffed by (the) team from the U.S. Public Health Service Corps—a nurse’s aide named Rachael Walker went in for treatment and left Ebolafree. And I want you to listen to what Rachael’s sister said about all of you. ‘We were worried at first,’ she said, ‘but when we found out [Rachael] was being transferred to the American Ebola treatment unit, we thanked God first and then we thanked America second
for caring about us.’ And the Americans who she was speaking of aren’t just doctors or nurses, or soldiers or scientists. You’re what one lieutenant commander from the U.S. Public Health Service Corps called the ‘hope multipliers.’3
The USPHS Commissioned Corps and the Office of the Surgeon General were proud to be part of the public health response. Our mission was to assist the Liberian people, and the officers who served there gave of themselves. But I learned long ago that service to others is also service to oneself. As I watched the officers return from Monrovia, from the youngest lieutenant to the most senior flag officer, I could see in their faces the fulfillment that service had brought to each of them personally. Serving the underserved and vulnerable half a world away from home—yes, I think “hope multipliers” is a good way to describe it. Boris D. Lushniak is the former Acting Surgeon General and former Deputy Surgeon General of the U.S. Public Health Service (USPHS). He retired from the USPHS on October 1, 2015. Address correspondence to: Boris D. Lushniak, MD, MPH; e-mail .
REFERENCES 1. The White House (US), Office of the Press Secretary. Remarks from the president on the Ebola outbreak. 2014 Sep 16 [cited 2015 Aug 28]. Available from: URL: https://www.whitehouse.gov /the-press-office/2014/09/16/remarks-president-ebola-outbreak 2. In memoriam. J Environ Health 2012;74:52. Also available from: URL: http://www.readperiodicals.com/201205/2648043231.html [cited 2015 Aug 28]. 3. The White House (US), Office of the Press Secretary. Remarks by the president on America’s leadership in the Ebola fight. 2015 Feb 11 [cited 2015 Aug 28]. Available from: URL: https://www.whitehouse.gov/the-press-office/2015/02/11 /remarks-president-americas-leadership-ebola-fight
Public Health Reports / November–December 2015 / Volume 130
