Afterwards, things settled down for Fowler until 2009 when a respiratory illness began sweeping through Mexico, the southwest United States, and Canada.  Given the extreme Canadian winters, it was not unusual for plenty of Canadians to travel south to Mexico and escape the cold.  As a result, this mysterious respiratory illness, later identified as a novel H1N1 Influenza A virus, was brought back to Canada.  Patient zero was felt to be a 6-month-old girl from Northern Mexico who presented on February 24, 2009.  Within one month, the Mexican Ministry of Health reported 2155 patients with severe pneumonia and 100 deaths.  The first cases soon followed in the US and Canada.  Epidemiologic data tied the dissemination to international air-traffic patterns, according to a study in the New England Journal of Medicine.  Dr. Margaret Chan declared the outbreak “unstoppable,” and noted that most cases involved patients 25 years old or less, 1/3 of which were previously healthy individuals.  Before it was over, the swine flu, as it became known, effected 60 million patients in the US alone, leading to 274,000 hospitalizations and 12,500 deaths. WHO estimated it caused somewhere between 150,000 and 575,000 deaths worldwide.  The H1N1 Strain was novel because it contained a unique combination of gene segments not previously identified in humans or animals.  It contained segments from North American swine influenza viruses, North American avian influenza viruses, human influenza viruses and Eurasian swine influenza viruses.  WHO official declared the H1N1 outbreak a pandemic, the first pandemic of the 21st century.  Although SARS was more lethal and did spread globally, it was relatively contained though public health measures with only 8000 cases worldwide and 774 reported deaths, thus it was not officially labeled a pandemic.  The two outbreaks had different etiologic agents:  SARS was a corona virus, H1N1 was an influenza virus. 

Fowler received a call from a fellow critical care doctor who was contacted by National Public Radio in the United States for the purpose of giving an interview on the emerging swine flu pandemic.  He confided to Fowler that, besides it causing Acute Respiratory Distress Syndrome, or ARDS, he didn’t know much about it.  Because of Fowler’s SARS experience, he referred NPR to Fowler.  Fowler did the interview and was subsequently contacted by another critical care physician from Mexico he had met years before.

“He was getting overwhelmed in his hospital in Mexico City because of the H1N1 cases.  Because of my SARS experience, he asked for advice on what they should be doing in describing their experiences and also projecting forward what they might need, as things were worsening.  I sensed they were starting to become overwhelmed, running out of ventilators and not sure where this was going to go.  I was able to mobilize the Canadian Critical Care Trials Group, a terrific clinical academic group, to help with the Mexico outbreak.  Because of the outbreak, I feared not being allowed back into the US or Canada, so I arranged to meet my Mexican physician in San Diego.  He would drive across the border, and we would go over his findings and I would start to organize the data.”  Cases began to seep across the porous borders of the United States and Canada.  Dr. Fowler became the interchange between the Mexicans and the Canadians, and the Canadian Critical Care Trials Group began to compile a bi-national comparative study on the outbreak. 

“We began to notice that the mortality rates, adjusted by severity of illness at presentation, were vastly different between Mexico and Canada.”  Mexico simply did not have the capacity to care for patients at this volume, and Canada did.  At this level at least, compared to Mexico, Canada had enough hospital beds, staff, oxygen, fluids, radiologic services, ventilators and other resources to make a noticeable difference in mortality.  The difference was not better doctors or hospitals in Canada as one might initially conclude, but the resources and capacity to stem the tide of the patient’s illness with continuous and appropriate supportive care. 

“Eventually, based on my H1N1 experience, which was based on my SARS experience, a colleague of mine in the WHO, who I had been interacting with through these outbreaks, invited me to do a sabbatical in Geneva in developing a case report form that WHO might eventually use internationally to deal with uniform data collection for epidemiologic purposes of a future infectious outbreak.  We were looking to describe things, from different countries, the same way, so we could keep our signals uniform.”   With no salary, but a guarantee to help cover expenses adequately, Fowler moved the family to Geneva in 2013 for a year, where he immediately took up work on a new outbreak called MERS, or Middle Eastern Respiratory Virus, caused by a novel corona virus, a lethal zoonotic disease spread by direct contact between camels and humans.  Fowler began working with critical care doctors in Saudia Arabia and around the Gulf on the epidemiology of the emerging MERS epidemic, which effected 2600 people and caused 900 deaths.  Patient zero was said to be from Jeddah, Saudia Arabia.  During this outbreak, a case report reached WHO about a man in Guinea, West Africa, who had reportedly died of a viral hemorrhagic fever.  A small group was dispatched to Conakry, the capital of Guinea, including Fowler and an infectious disease physician from the United Kingdom, Tom Fletcher, along with a few epidemiologists and communications technicians, to study the situation. 

“Within a day, it was clear that there were lots of what turned out to be Ebola Virus already in Conakry and unrecognized.  The hospitals were emptying out as people realized there was something happening, and patients and staff decided to leave the hospital because they were getting a sense they were at risk of getting whatever it was.  When we arrived, the ward looked like there was one remaining nurse and maybe one remaining doctor caring for a dozen patients of which five were healthcare workers.  Two of these patients were already dead in their beds.  They had all been caring for patients who were admitted over the last two weeks.”  Cases began to pile up.  A private hospital in Conakry, set up to care for the needs of expats and mine workers, had already been overwhelmed and shut down.  Hospital administrators were aggrieved.  “They said, “You have to take these patients someplace else.  Set up something for them.  This is not what our hospital does.”  All of a sudden, we were the WHO representatives there at the pleasure of the Ministry of Health.  We were the so-called experts, despite neither of us having ever seen Ebola before.  We were being asked to solve this clinical problem.”  The hospital administrators were panicked.  They were losing money on the cancellation of their elective surgeries and their reputations were felt to be at risk.  Nobody wanted to come near a hospital.  This was the last thing they wanted to be involved with. 

As a result, Fowler and his team were offered an old cholera treatment facility, connected to the main hospital in Conakry, which was empty.  It was more than empty; it had been abandoned.  “There was no cholera at the time.  There were a couple of cholera cots, but that was it.  We negotiated with the hospital administrators to say, “If you want us to take your patients, we also have to take all of your medical supplies.”  Initially, they said no.  Fowler and Fletcher explained that organizing medical relief from WHO would take time.  It would be a while before things could be brought in.  With that threat, the hospital relented and essentially told them to take anything they wanted but just get the rest of the Ebola patients out of there today.

“We loaded up one ambulance with all the pharmaceuticals and supplies and with the other ambulances, we started moving the patients over to the treatment facility.   Over the next several months, with help from Medecins Sans Frontieres (MSF or Doctors Without Borders), we sort of transitioned that decrepit facility into a reasonably functioning internal medicine ward for sick patients.  It was basic, though.  There was no oxygen for them, yet.  So, if they developed respiratory trouble, you had no way to support them.”

“We had antibiotics, anti-malarials, and intravenous fluids.  The patients were getting sicker, and we could see what was happening clinically, but we didn’t know what was happening physiologically.  There wasn’t a lot described with Ebola to date.  There was the notion that people bled and probably died of hemorrhagic deaths.  But that didn’t seem to be what we were seeing.  There certainly was an end-stage hemorrhage in some of these patients, but people were getting really sick without any signs of outward bleeding, at least gastrointestinal.  We sort of begged a point-of-care blood testing machine from MSF to be sent over from Europe.”  Other local facilities and hospitals refused to accept the blood from the Ebola center.  Eventually, the machine arrived, and the two physicians were able to sample blood for complete blood counts, liver function tests, and electrolytes and creatinine.  While theoretically possible, a viral load could be sent out to Europe but by the time results were returned, the situation would have rendered itself moot.  The patient would either be dead or recovered. 

“The machine we were using, an ISTAT machine, would only operate under a relatively narrow range of temperatures.  This was now April in Guinea, and it was getting darn hot, like, 30 to 35 degrees Celsius in the daytime.  So, we could only draw blood and process the labs in the morning.  If you coated the machine in ice packs before it shut down, sometimes you could get away with it.  Otherwise, the machine wouldn’t work again until later in the day when the temperature had gone down.”  Talk about overcoming obstacles, Fowler, with no prior knowledge on Ebola virus, found himself as the WHO’s perceived expert in Guinea, one of the poorest countries on the planet, with virtually no resources, including oxygen, limited staff and protective gear, and an old ISTAT machine that had to be nurtured like a diaphoretic, feeble old man during  a sweltering heat wave, in order to deliver basic laboratory data, and that’s on a good day.  “We would be saying to ourselves, “How is this helpful other than morbid curiosity?””

Clearly, Fowler and his team found himself behind the eight ball.  But when you have nothing, everything and anything could be helpful.  “We’d see that this person’s potassium is 7.2 and his creatinine is, say, 5.0, and it would be evident why this person is getting critically ill.  Some of it could be treated with volume resuscitation or at least temporized with potassium binders.  We could supplement or try to reduce phosphorus issues, hypo or hyper.  And there are certainly intravenous fluids we could give.”  Even though he couldn’t initiate dialysis or have at his disposal other life-saving options, Fowler put his best foot forward in trying to make the best internal medicine unit he could under the circumstances.  Fowler was also hamstrung in that there were no effective anti-Ebola treatments at the time, but he did his best to support the patients, treat any secondary bacterial or malarial infections, and persevere through the extremely difficult and trying circumstances he found himself thrust into.  He was sent as an Ebola observer and, for the sake of humanity, took it upon himself to become a front-line worker with a disease that had a greater than 90% mortality.  Fowler represented the embodiment of the definition of both physician-dedication and courage.  He and his partner truly tried to stretch the limits of what they had available, giving the patients at least a fighting chance, rather than just direct traffic and apply window dressing on what appeared to be a fruitless mission of medical diplomacy. 

Fowler was also hard at work at optimizing his case report forms for WHO.  What he found was that mortality in patients presenting to his clinic was just 40%, compared to 80-90% in the bush.  Providing only what we think of in modern medicine as supportive care had a dramatic effect on reducing the mortality rate.  “So, we started to think, maybe if we focus on providing care, these patients do a bit better.  And knowing what’s happening with their physiology, what’s deranged, through labs, maybe this is important in making a difference.”  Clearly it was.  Fowler was able to take a disease that was considered near universally fatal and cut the mortality rate in half with basic efforts. 

“The next few months was also focused on trying to mobilize resources and staff from Europe and North America, to come and help, to aid the population, including the medical population, the doctors and nurses, who were decimated by the outbreak.” Fowler admits that through it all, it was hard to stay positive.  There was, in addition, fear of his own well-being, and, in the beginning, an underlying sense of the futility of it all; Afterall, they were all going to die anyway, according to the textbooks.  He tried not to let these rationalizations get the better of him and his will, his dogged pursuit of delivering everything he had to give under his power.  “And there was a huge debate in the summer of 2014 about whether treating patients was just going to lead to more healthcare workers getting infected.  If you’re putting in and replacing iv’s, and drawing their blood, and having close contact, if people couldn’t just drink oral rehydration solution, were you just going to end up making it worse by exposing and depleting the healthcare workers?  There was a huge debate among NGO (non-governmental organizations) about whether this was just an unsafe environment to expose our people to versus how we can provide for these patients and this circumstance.”  Eventually, with the expansion of Ebola into neighboring Sierra Leone and Liberia, the pendulum swung to the side of attempting to deliver the best possible care to these patients, irrespective of outcomes or uncertainties.