More than a disease

As their December 2014 graduation date neared, MSN students Mary Micikas and Becky Schicker were making plans for a dramatic career step. Both had been hired by the Boston-based agency Partners in Health to care for Ebola patients in West Africa. Both are now emergency nurse practitioners also trained to assist with complex humanitarian emergencies (CHEs) around the world.

The nurses came by their CHE training via different paths. Schicker 14MN/14MPH earned a certificate in Global Complex Humanitarian Emergencies at the Rollins School of Public Health, while Micikas 13N 14MN, a Fuld Fellow in the School of Nursing, completed a new CHE course at the nursing school this past fall. Funded by the Helene Fuld Health Trust, Fuld Fellowships prepare second-career students like Micikas to serve vulnerable populations.

She signed up for the three-day course last June, weeks before the world knew the full extent of the Ebola outbreak in West Africa and before the first U.S. patients with the virus arrived from Liberia for treatment at Emory University Hospital. The timing of the course proved serendipitous for Micikas, who received a job offer from Partners in Health the day after the CHE course began. 

“It’s a great model,” she says of the class. “It’s amazing how much we learned in three days.”

In that short period, 21 students interacted with CHE experts from Emory, the CDC, Doctors Without Borders, the Carter Center, and CARE. They examined the global standards that guide humanitarian practice such as Sphere Project guidelines, widely used by the humanitarian aid community, and the Minimum Initial Service Package for reproductive health in crisis situations. They also collaborated on case studies illustrating the scope and challenges of humanitarian aid work during and after a crisis.

Students quickly learned that CHEs require nurses to be strong leaders who can step into different roles as needed and understand cultural and other factors unique to each situation. The Ebola epidemic exemplified in real time the complicated nature of CHEs, which are defined as manmade disasters that far surpass a country’s ability to abate a crisis. CHEs are rooted in conflict and poverty and may be triggered by a natural disaster or health epidemic.

“When you work in CHEs, you have to be aware of the social, political, economic, epidemiologic, and cultural aspects of everything that’s going on,” says course co-leader Elizabeth Downes  04MPH DNP MSN RN CNE FAANP ANEF. “In West Africa, the impact of Ebola on direct patient care alone is huge. But it’s also taken a toll on health care workers who have lost colleagues and are exhausted.”

Downes speaks from experience, having worked in Africa as a Peace Corps volunteer, family nurse practitioner, and nurse educator. Among her assignments: managing a project to assist war and landmine victims in Mozambique, including amputees. She currently is an academic consultant for a Carter Center program in Liberia that trains nurses and physician assistants to diagnose and treat mental health disorders. The Ebola epidemic has further strained the nation’s fragile mental health system, which has one psychiatrist and one psychiatric hospital serving a population of 4.2 million people. Of the 144 mental health clinicians trained by the Carter Center thus far, one has died and one has survived Ebola. With Downes’ help, the Emory International Student Nurses Association conducted a fund-raising drive to support the mental health clinicians.

In the CHE course at the School of Nursing, Downes and co-leader Holly Williams PhD MN RN, a nurse anthropologist/epidemiologist with the CDC and a captain in the U.S. Public Health Service, provide insight on the myriad roles that nurses play in emergencies—managing a hospital or its staff, providing patient care, educating health care workers, caring for orphaned children, or running a pharmacy, nutrition center, or mental health facility. “Nurses have to be everywhere,” says Downes.

The instructors also stress that nurses plan ahead to stay healthy. That includes finding a safe place to live, arranging for safe food and water, paying attention to cultural norms and surroundings to ensure their safety, and knowing what to do in case of evacuation. Such details are spelled out the first day of class. 

“It’s critical that you take care of yourself,” says Williams, who serves with the CDC ’s Emergency Response and Recovery Branch (ERRB). “If you can’t take care of yourself, you can’t take care of others. Your judgment starts to fail and you make mistakes. That can be deadly with diseases like Ebola.”

Williams is among the ERRB experts who teach students in the Global Complex Humanitarian Emergencies certificate program at Rollins. She proposed creating last fall’s CHE course tailored just for nursing students. Williams also serves on the advisory board of the Lillian Carter Center for Global Health & Social Responsibility at the School of Nursing.

“CHE work isn’t for everyone,” she cautions. “It takes a personal toll when you work in these settings. Nurses must use skills way beyond what we traditionally teach them. The reward comes in seeing an immediate outcome by touching someone’s life in a situation of extreme distress.”

Schicker and Micikas were mindful of the challenges as they prepared for their assignments in West Africa. While there are many unknowns, they are confident in their ability to partner with health care workers, community and government leaders, and others to bolster health systems weakened by Ebola.

“Integrating what we know from our advanced nursing training at Emory into another country’s context goes beyond our traditional training in emergencies and necessitates incorporating the skills we learned from the CHE classes,” says Schicker. “Regardless of how damaged their current health care system is, we are there at their invitation, and it behooves us and everyone else to coordinate with the systems already in place.”

The new graduates also expect to experience heartbreak. “The thing I’ve thought about most is dealing with death—both patients and staff members,” says Micikas, who founded a rural health clinic in Guatemala before studying at Emory. “I think that will be the hardest thing to cope with.” 

Schicker is more accustomed to facing death, having worked as an emergency room nurse in Michigan and New York, where she had ready access to modern health care tools like technology, medicines, equipment, and specialized expertise.

“When a patient died, I felt I had done everything in my power to keep them alive or alleviate their suffering,” she says. “That’s more difficult in resource-poor settings like West Africa. Doing the best you can with what you have for a patient is a hard thing to come to terms with when you’re used to taking care of patients with all of
the resources imaginable available to you.”

Related Resources

More Ebola stories at Emory (Emory News Center)

"School of Nursing alumni discuss successful treatment of Ebola patients" (Emory News Center, 2/12/2015)

"Three Emory nursing grads part of Emory's Ebola team" (Emory News Center, 12/18/14)