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It’s not easy... but you just have to go in and do your job. You have to be able to do your job to keep doing this and there’s certainly lots of positives.

Libby Bowell, infectious diseases nurse and international health aid worker
Libby Bowell

Fighting 18th century diseases in 2017

Special guest: Libby Bowell, infectious diseases nurse and international health aid worker 
Host: Susan Cullinan, Australian Red Cross

 

Susan
How do you fight an epidemic like cholera? Why does cholera still exist? And do factors such as war, climate change, drought and famine create the perfect storm for these epidemics to threaten millions of lives? I’m Susan Cullinan and with me is one of the world’s foremost experts on tackling diseases like cholera and Ebola, Libby Bowell, who joins us now for our next episode of “How Aid Works.”  Welcome Libby.

Libby
Thank you

Susan
So tell us a little bit about you experience in taking on these diseases? Where have your assignments taken you?

Libby
I guess when we’re looking at epidemics, for the most it’s in Africa so I’ve worked now on about four cholera outbreaks in Sierra Leone, Liberia and most recently in Somalia but also I went to one in PNG. And of course Ebola was in the far west of Africa and my role there was as a Health Coordinator for in Liberia. 

Susan
So most people wouldn’t have a clue with epidemics like this particularly cholera, still exist. But what sort of reactions do you get when you tell people in Australia about the sorts of things that you come up against?

Libby
Well I think it’s right I think that it’s not big headline stuff and so people don’t hear about it and when they do I think again just what you said they don’t think that it still exists. I guess people are interested in how we fight it and why it still happens but I think it’s one of those things that as an aid worker we understand and accept that it hits the news maybe and then it drops out.

Susan
So for those people who are listening in who are keen to hear a little bit more, tell us about what it’s like on the ground, when you’ve got an epidemic that’s threatening people on a huge scale?

Libby
Well I guess the problem is that the epidemic is often the tip of the iceberg. These epidemics or outbreaks have been in countries that are suffering so there’s already a high degree of poverty. It’s often in a country that has unrest politically and it may or may not as in the case for Somalia have really high rates of malnutrition and the same with education. Education levels might not be as high as what we see here so you know basic things around just the connection between good hygiene and breaking the disease transmission is just not known.   

Susan
So what do you do? You arrive…

Libby
Yeah.

Susan
What happens next? You’re faced with this extraordinary health challenge. You roll up your sleeves, get to work and tell us what you do.

Libby
Yes but I guess it depends for us to go into any country we have to be invited so first the country of origin has to say ‘we have an emergency situation’ and then they put out the request for help. And so that clearly goes up to our headquarters in Geneva and then they determine the team that needs to go in. From a health perspective then it’s about hitting the ground and  you know we do a lot of what we call ‘analysing secondary data’ which is making sense of what information is already there and what other you know, there are usually local responses but they have exceeded their capacity. So it’s about gathering all of that information and then and, and you know now with the world as it is with the Internet then my task, as soon as I know that I’m on my way, then I start working from here and finding out you know what does the World Health Organisation know about it and what’s the situation from the UN perspective or is Red Cross already on the ground there, what other agencies are there? So it’s about putting together a really big jigsaw puzzle before you get there and so that you can have some, I guess educated sort of overview and then you start to look. So from the Red Cross perspective the most wonderful thing about working for the Red Cross is that there’s national societies in nearly every country and they’re already going to be doing some of the work even if they’ve met their capacity Red Cross are so community orientated that in these countries there’s always going to be some sort of relationship between the local national society and the communities. So it’s about working with them as well and then continuing to put the jigsaw puzzle together, you know trying to establish meetings with other players, trying to look at all the health facilities, hospitals and health facilities that are there, and then determine the response that we can do. Then it goes back up the chain and then the response starts and depending on where we fit in to the picture, how big a response we do whether it’s all community driven or whether we are in fact going to put up a you know a cholera treatment centre or an Ebola treatment centre.

Susan
So it takes much more than chlorine and isolation wards to fight epidemics?

Libby
Yeah it does but they’re two really crucial parts you know chlorine and good old soap and water can  help break the transmission but people have to understand why they’re washing their hands, how that does really get rid of the germs and that’s one of the most key parts of the solution is to try and get people to understand the role that hygiene plays in all of these disease.  Certainly we have to have a mechanism or a platform to treat people so in the case of Somalia we put up a cholera treatment centre which was 100 beds, we put up a treatment unit that was 25 beds as well as we put in 100 community-based oral rehydration points which are places for people to come and have a drink of oral rehydration salts and hopefully cut them off before they progress to a more severe state and require intravenous fluids so there’s all parts to it but you can’t stop it without raising the awareness and the educations level at a community level about basic hygiene measures. And it’s easy for us in these countries that we live in to think that that’s an easy thing but if you look in Somalia right now they have a drought, they didn’t get the rain in April/May that they were meant to get, they are  highly likely not to get the rain in October, so it’s a protracted drought. We have a lot of nomadic people that move to try and you know either raise their livestock or grow their agriculture and that’s not successful at the moment. More than 80-90% of the livestock is all gone. You’ve got people having to move because of political unrest or because they haven’t got access to food and water. If you’ve got a drought then dams dry up. The water that’s there is really contaminated so it’s got to be addressed at all of the levels and there has to be a massive community focus.

Susan
So the situation in Somalia hasn’t got much of the world’s attention, sadly, but by contrast the Ebola epidemic really did seem to grip the West, possibly because it was so terrifying, and final. Tell us what that was like working with patients who had Ebola, what was it like for you? You were in amongst it?  

Libby
Yeah look certainly the risk was higher but also you know working for an organisation like Red Cross, my training has also been high, and you know they expect us to work to a standard, so our knowledge is there on how not to get Ebola and again it came down to chlorine and soap and water will break that transmission and of course we had to keep a distance and not have a, you know shake hands and touch people. So that’s always difficult. That probably was more difficult as being a nurse so that was – there were definitely challenges there but again I think it was – it’s kind of sexier than cholera is because cholera’s around all the time and Ebola  – maybe it was because this was one of the things that had a potentially a threat to the western world. But of course we have in every facility in Australia, we have the ability to isolate people, to put drips in people, to wear protective clothing and I think the western world reacted, of course, through fear and we had a – but we also had such a high death rate and a such a fast-moving epidemic there. I was based in Monrovia and the last thing you ever want to see is an outbreak in a capital city especially one that has slums and that’s what happened to us and so that was definitely a race against time. But as always the people were fantastic. I worked with a great national society there and we just, you know you had to try and stay in front of it so you had to have careful planning, careful assessment and really again target at the community level. Unless you can break that transmission at the community level when people move all the time, then that’s where you know the problem gets worse. So I think Ebola was perceived as more threatening to us here and in all western countries and that’s why it got the attention that it did and it had such a scary rising  death rate at the time.

Susan
The death rate was shocking.

Libby
Yeah.

Susan
And I think those images too of people treating the Ebola patients were also terrifying.

Libby
Of course it was awful, it was awful sending out teams of predominantly young men to pick up bodies every day but you know they take it in their stride and they really believe that unless they help them, the thing is not going to go away. The reality of cholera is you can probably look into Africa on any given day of the week, and there’s at least half a dozen outbreaks happening but it’s not something that probably brings the high death rate, and it’s probably much more common so it just doesn’t rate much of a mention. But it’s a serious problem.

Susan
And for you personally, now that the Ebola epidemic has been more or less broken, how does that feel?

Libby
Oh it’s great I mean there’s been certainly cases this year but the training – I mean in all of what we’re doing with Red Cross, whenever I go on a mission and I know all of us do, part of our job is to capacity build. We want to be able to come home. So we have to make sure that we are guiding, teaching facilitating our knowledge and help building the national society and while we’re there so we can go home. The proof is in that with the ongoing cases of Ebola in countries since we’ve left. It just gets shut down very quickly because people can move and understand what has to be done. There a lot of myths and you know conspiracy theories with Ebola and that’s not there now I don’t think – I think people just know “Ok this is the disease and this is how we treat it and this is how we stop it.”

Susan
Again on a personal level, if you don’t mind talking through, how do you cope, personally with seeing the level and the scale of human suffering that is part of your job?

Libby
I think you know a big part of it is, is that I understand that it’s my job. And I’ve been a nurse for a long time so I’ve worked in this field. I’m not downplaying it or saying that it’s easy, it’s not easy seeing certainly the high rates of malnutrition that are in these countries that have currently got cholera but I think you just have to -  you have to go in and do your job. And you have to be able to do your job to keep doing this and there’s certainly lots of positives. You know every time I go in I just feel privileged to work with the national society that’s there. I’ve just come away from working with one of the best heath teams I’ve ever worked with in Somalia. So I think you just make sure that you are able to do your job.  We spend time as a team debriefing when you have to and when I come home on a personal note I spend a few days of being relatively quiet. It’s coming back and talking about a mission to anyone it doesn’t matter whether people are interested the truth is it’s like looking at a photo album of somebody that in the old  days when you put your album of your holiday snaps in front and by the third page people were kind of moving on and you know more interested in something else. That’s the reality. We do the job, you come home, you debrief, you put a lid on it and you move on.  

Susan
So your top tips for keeping you going? I think you sort of mentioned the awesome support of your colleagues in country and then the I think you’re talking about self-care when you return?

Libby
Yes I think the biggest tips you know you have, for me I have certain things that I have to line-up when I’ve been asked to go and if I can’t line all of these things up which are family and work just you know whether I’ve had a break or whatever, but you have those that you line-up each and every time and if you can’t then you don’t feel bad that you say, “No I can’t go.” And I think that’s the most important thing, because when you go, you know in Somalia it was six solid weeks of 16 to 18 hour days without a day off.  

Susan
Wow!

Libby
So you’ve got to be ready to go and you’ve got to know that you’re going to work that hard. So if something in those lines - that whatever it is that’s important to you, if something doesn’t line-up then it’s probably wise not to go. And it’s I guess the other thing is it’s okay to say “No”. But if you - and then you just you know for me if I can do a bit of exercise when I’m away that’s important, this time that was really difficult because of security reasons so but then I found a 7 to 10 minute you know yoga app that I could download so it just – find out what works, what’s important for you and try and keep some of that in, in your mission.

Susan
Have you got a story you can share about the most unlikely thing that’s happened to you whist you’ve been on a mission?

Libby
It’s a really difficult question because I take each mission in my stride and I think different things happen to you all the time. You know and I think it can be from – I don’t really have stories. You know I think what’s different in when you go away and do this is this time I met with, you know I met with the president of the country. I met with the health minister you know because of the profile that we have and Red Cross has in Somalia. For me I was meeting with really high ranking people on a almost a daily basis and that’s an  unlikely thing to happen to me in this country but it’s part of the job that we do when we’re away. I guess, just I go there knowing that I have a – and I may have been in the country before but often I’m in different countries and so many unlikely things happen but I don’t really have a story that stands out.

Susan
Every day seems so unlikely I suppose and you just get on with it.

Libby
Well every day is different and every mission is different and I’d often – I remember you know I’ve done 25 other missions with Australian Red Cross and I remember after about the twelfth they started saying I was a senior delegate and I used to shudder at that because I thought just one more mission and I’ll just have this down-pat and that’s because every single mission is contextualised and every single mission – even if the core role of what we do is the same, it’s got to be contextualised to the country you know. The hardest thing for me in Somalia was working in 42 degree heat and having a hijab on my head you know and not – and trying to do that with without looking like I had been dragged around the garden you know a few dozen times because I sweated beyond belief.

Susan
Sounds very hot.

Libby
But you know probably the unlikely thing that happened was I coped with it and I got better and I stopped sweating after the first couple of weeks so.

Susan
That’s interesting.  You acclimatised?

Libby
Yeah you well you have to, it’s so hot.

Susan
So the local women don’t sweat as much then?

Libby
No definitely not and we were there during Ramadan and so we had to respect that we couldn’t reach for a drink in the middle of the day and so we were probably working quite dehydrated on top of everything else.

Susan
It’s extraordinary. But everyone would have been dehydrated all around you?

Libby
Yeah of course, of course. But talking to them and why they do Ramadan and you think so they can when they tell me that so they can appreciate what it’s like to suffer when you’re already in the country that’s doing it so tough and it’s not something you know that we would even really contemplate [in the West] or think that we should do.

Susan
Experience toughness?

Libby
Yeah. For a whole month. Every year and the kids start doing it from the age of about 8 or 9 and so you know I just have the hugest respect for them that they can do this and they do it for those reasons.

Susan
And do you think that that strength and resilience actually helps when it comes to health outbreaks, you know epidemics?

Libby
Yeah absolutely it does, they’re so much more accepting. You know I saw a lot of kids die on this last mission and when you talked to staff about how they were going and whether they needed five minutes out like it’s so normal in Australia if, coming from emergency department background that if you had a terrible trauma then you know you would clean up but then everyone would have just a debrief, get outside, you know smoke a cigarette, eat an apple, just stand outside and just chat, but have a break from what you just dealt with before you start again. Whereas, trying to encourage local doctors and nurses to step outside the CTC and just have a breather if it was a particularly traumatic death, was just not really in their repertoire of options really. They’d go, “No no, no I’ll just keep going now you know. God wanted the child more than us and so they’ve gone.” And in their culture it was very important for the body to be removed very quickly like within thirty minutes and then for burial so they would  just move on.  

Susan
So the stronger constitution as a result of this lifetime of hardship in a sense?

Libby
Hardship and belief. Their belief – you know their Muslim belief or their Islam belief is so strong that it helps them deal with this. You know their faith is so strong and they just see that this is the way it is.

Susan
So when you’re away from that culture so incredibly different culture, do you miss it when you come home to Australia?

Libby
Oh I could go back there in a heartbeat this time because they were such fantastic people to work with and most of the time they are. Yeah I think coming home is always more difficult because there’s never a good time to leave. You know you can stay and my counterpart there Caltoun  said to me it was leaving a hole in her heart. I have a very it’s my own coping way of dealing with it I never tell people I’m going until the day before, because you don’t want them – we have a job to do and you don’t want them upset by you going and I work really well with national societies but when Caltoun said that to me on the last day I went, “Oh no don’t do that to me please. You know, I’ve got to go.” and I’ve been doing this for a long time you know I could stay I could go back but I have commitments here as well, and I have a life here and it’s okay to come home and you’ve got to come home before you go again.

Susan
So what is the nicest thing about your work when you’re over in these incredible situations?

Libby
Oh I think it’s a huge privilege to be able to do this. We get into areas where people would never have an opportunity to go to. I get to understand what it’s like for people to do it pretty tough, not that it’s a great thing but I get to – I guess it’s as kind of as corny as it sounds, we do get to make a little bit of a difference in these countries. That’s not as easy to say here that we get to make a difference. So I think it’s the privilege and the opportunity to make that little bit of difference even if it’s just chipping away in the right direction or just taking the load off the local staff to help them get to the next level, then you know that’s just a huge  honour and privilege.

Susan
And I love that, I love how you talk about the difference even if it’s a small different, can you tell me a little more about that? Is it one patient at a time?

Libby
Years ago I worked in the Solomon Islands on a, it was called Healthy Living Together, it was a water and and sanitation public health project, and a priest said to me for forty years I’ve had diarrhoea, now I understand how I get it and how to stop it through good  hygiene I’ll never have it again.

Susan
Good Lord. Forty years of diarrhoea?

Libby
Yeah.

Susan
That’s more than a little difference Libby!

Libby
Yeah well to one person you know but we did see big differences there. But in all emergencies, in outbreaks when you can make that transmission, when you can build that knowledge, when people actually choose to change their behaviour because they understand, and that’s the probably the fundamental key is anyone can go out and put posters up. Anyone can say if you do this this’ll get better, or if you do this this will get worse. But if you actually can facilitate that knowledge at a local level and people, and the penny drops and then they go, “Okay we can fix this, we can stop this from happening and I saw that in you know, Ebola and I see it in cholera all the time when people understand this and it’s just basic knowledge that we get taught from the time that we start putting food in our hands.  But if people don’t have access to clean water, to wash their hands all the time, their access to water is so limited that they don’t have the ability to make clean water in order to drink or they don’t have rubbish bins, they don’t have jobs, they don’t go to school, then  how do you learn this knowledge. So if you can impart that knowledge and people then go, have that real, “Aha!” moment where they can change their behaviour then we can see huge changes. And that being part of that is a huge privilege.

Susan
And it’s not only developing countries where you are working as a nurse. When you are in Australia  you go to remote Indigenous communities. Are there similarities there to the type of work that you do?

Libby
Probably with some the disease patterns, yes the disease patterns that we have in our Indigenous communities are staggering. And there’s certainly been changes and some wins over the years but the statistics are still in some situations developing country statistics. Our opportunities are greater even though the further remote you get the more isolated people are and their access to you know hospitals and a choice of shops and a choice of doctors or pharmacy, all of those things aren’t there so of course they’re marginalised and it’s tougher and I love the work but it’s – there’s small parallels between this and international developing countries but the funding is far greater in Australia than it is in any developing country and so there should be things that we can do to change but sometimes I’m not sure that we want to hear that people don’t understand about good hygiene in our country because we’re a Western country. And we should all know that but there are definitely developing country situations because of the remoteness.

Susan
And what it is that keeps you coming back? Tell us about the community there’s one particular community where you’ve been working in Australia, why do you keep going  back to that one, tell us about that?

Libby
I think because I again I know the people, I know the older people really quite well because I’ve been going there for fifteen, probably closer to twenty years on and off. From a medicine perspective it’s challenging, you know remote area nurses work at a broader scope of practice than in hospitals so you know you have to have good assessment skills, you  have to be able to consult via phones and  you have to bring in retrieval services to get people out so I guess it’s that challenge, it’s the challenge of not looking at someone and going, “Oh yeah that’s an ear-ache.” It’s just you  have to go from  head to toe on just about everyone because there will be many other complicating factors and so I guess it’s that that’s keeping me on my toes, it’s the challenge is good. There are definitely comparisons between anyone that wants to go and work international, that I would recommend to go into remote Australia first because it teaches you about working with less resources, it teaches you about working in isolation, it teaches you about working away from home, it teaches you about other cultures, and marginalised people and teaches you about working with people in which English is maybe their third or fourth language. So it’s a best breeding ground, training ground for Australians and that’s well from a health and an environmental health perspective, it’s incredibly well-recognised internationally amongst other- amongst Red Cross and amongst other agencies. So for anyone that wants to do this work I would strongly recommend get out there for a minimum of three months but you know go for a good year at least.

Susan
So on a professional level it’s challenging which brings its own rewards I sense that there’s also something about you that likes to go to where the need is greatest?

Libby
Yeah well if you’re going to work then you might as well and you’re trained to do this and you like this of course it’s great to be challenged it’s great to bring something to it and feel like you’ve achieved something when you leave so if you’ve got to go to work then you know it’s good to work hard, and I’m happy to work hard and I’m happy to learn all the time and I’m happy to share what knowledge I’ve got so I think that both the Red Cross and working in remote Australia give me that.

Susan
So I think one final question to people who are listening who are really  keen to know more about how aid works, maybe they’re interested in a career or supporting the type of work that you do, what advice would you give them?

Libby
Well now you know when I did it way back when, you know you were limited to ringing people up to find out about it but now the Internet and Google are fantastic things and I would say look at what field you want to be in and be prepared to change. You know I was a very much die-hard emergency critical care nurse that now works in the public health field more than anything and I love it. I think you have to work out if you’re a flexible person and you can work with minimal – with changing, changing posts all the time. You have to be comfortable with levels of discomfort. You have to want to or be prepared to work for a lot less money most of the time and if those things and you want to go and do this stuff, and if those things are there then Google, look at the all the different studies that are there I would say gone are the days where people just can move from just one field into another without preparing yourself so there’s lots of study, international studies, public health, whatever field you’re in you’ll find lots of study around. Look at the reputable big organisations so look at Red Cross, look at MSF, look at Save the Children, look at World Vision, the UN all of those, and see how your profile fits with that because you’ve got to feel well supported. To me, Red Cross works for me really well, I believe in the Seven Principles, I feel really well-supported, the guidelines are really strict for me to work within but that keeps me safe and from a Red Cross perspective we’re in just about every country in the world and we have access very often sooner rather than others so for me it gives me just a – it’s been the right organisation for me. But I would say Google, talk to people, make contact with the organisations, look at your profile and then look at that organisation and see where you best fit.

Susan
Libby Bowell thank you very much and on behalf of the Red Cross, thank you very much and best of luck with your next mission.

Libby
Yeah thank you. Thanks very much.

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