Ebola: Learning the hard way.


David Kirk is a PhD student in Food Hygiene and Environmental Health at the University of Helsinki, Finland. He also blogs on current events in life science. You can read more from him at www.davekirksciencejerk.wordpress.com

Where are we now?

Ebola has infected over 9,100 people in west Africa since December of last year. The disease continues to spread within the region (now primarily affecting Guinea, Sierra Leone, and Liberia) and not enough is being done to stop it.
Ebola is spreading fast. Within the last 30 days, over 3,000 new people have become infected with Ebola. To put that in relative perspective, between December 2013 and mid-August 2014, the combined number of infected had just reached 3,000. The World Health Organisation (WHO) estimates the number of infected will reach 20,000 by the end of November. Over 1 million people could be infected in January next year at the current rate of transmission. Of these, 70% will die from Ebola.

As Ebola spreads out of Africa, questions are being asked. Could the outbreak have been contained early on? What will happen if it spreads? What will happen next time? To address these questions, we must look at the circumstances surrounding the initial outbreak.

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Ebolavirus – image captured by CDC microbiologist Cynthia Goldsmith, made available under Creative Commons licence.

Perfect storm
Before the outbreak in west Africa, Ebola was as common as malaria is in Ireland. The disease had never struck there before, aside from an isolated case in Ivory Coast some decades ago. As a result, people (and even some healthcare workers) would not have immediately assumed Ebola was the cause of the mystery illness gripping the region from December to March – when it was finally identified as Ebolavirus.

Timeline of the west-African Ebola outbreak

Given the head-start the virus had on the response teams, the Centers for Disease Control and Prevention (CDC) only sent a few personnel to the region to assist in coordinating a response to the outbreak. This proved to be ineffective, as Guinea, Sierra Leone, and Liberia all have poor infrastructure and inadequate healthcare systems. The infrastructure could not (and still cannot) cope with a disease such as Ebola: a disease that kills rapidly; causes vomiting, internal bleeding and diarrhoea; and spreads easily through contact with contaminated blood and bodily fluids. Healthcare workers are thought to have helped spread the disease in the initial stages of the outbreak.
Finally, there is a culture of care for the sick and respect for the dead in West Africa. Dead bodies are washed and the sick are taken care of by family members. Traditional medicine and tribal healers are frequently used, and some even distrust Western medicine. A lack of education regarding Ebola transmission and treatment of those infected is the second-largest obstacle still faced in containing the illness – the largest being the lack of infrastructure.
This Ebola outbreak is unlike any other, and perhaps that should have sent a red flag up in the eyes of the WHO immediately. They admitted recently that the organisation failed to see an outbreak of this scale occurring, according to a leaked internal report on the Ebola crisis. Ultimately, the national and international bodies involved simply didn’t act fast enough.
Expert opinion
Dr Noel Murphy, coordinator of the Masters programme of Immunology and Global Health at Maynooth University agrees, “Poverty, lack of knowledge and mistrust of Western Medicine are major challenges to containing any outbreak.” He also states that the response in tackling the outbreak was inadequate, “The International response has been abysmally slow and way too small, even the levels they are talking about now. If there was a natural disaster aid agencies would be in with tents, medical centres, medicines etc. etc. and still this isn’t happening. The African Union has also been inactive and ineffective. Things are only starting to move (and still too slowly plus a knee-jerk response) because western nations are beginning to be threatened.”
The WHO estimates that over $1 billion will be required to contain Ebola at its current levels but, as the outbreak grows, that figure is likely to rise. The biggest fear is Ebola spreading to neighbouring countries or to east Africa. Senegal and Nigeria have been declared Ebola-free after minor outbreaks, but the Democratic Republic of the Congo is still grappling with its own unrelated Ebola outbreak. Many African countries have closed their borders to the afflicted nations.
Dr Murphy, who has researched in Kenya’s International Laboratory for Research on Animal Diseases, was keen to point out that east African nations, such as Kenya and Uganda, would be better equipped to deal with an outbreak than the countries of west Africa. He says “Kenya would be best placed to address the problem because its infrastructure is generally better than neighbouring countries. The main worry is if an outbreak occurs in a slum such as Kibera in Nairobi (the largest of its kind on the continent) then it will be very difficult to contain.”

The next AIDS
The CDC said some time back that this crisis could become “the next AIDS”. In terms of epidemiology, the two viruses – HIV, which causes AIDS, and Ebola, are too different to be likened in such a way. Ebola, is not so insidious. It is spread through physical contact, but incapacitates and kills its victims much faster. Its symptoms are readily screened for (high fever) and much of the world is already on alert for an outbreak, so such a worldwide epidemic, such as that of HIV/AIDS, is highly unlikely.
That’s the biological assessment, however we may be looking at an AIDS-like humanitarian crisis. It has been estimated that 2.5 million people have been affected (not infected!) by Ebola in the region. Like AIDS, this indirect affect hits children hardest. AIDS orphans tens of thousands of children across Africa every year. In the last year, UNICEF have said that, out of 4,500 deaths recorded due to Ebola, more than 3,700 children have been orphaned. This is a significantly high proportion that could become so much more devastating if Ebola were to spread to more densely populated countries in the region.

What next?
The battle against is being slowly waged on two fronts, the healthcare and humanitarian, and the cost is increasing every day. It’s obvious to say more could have been done. It’s more obvious to say we should do more now.
What’s not being said is less obvious. What do we do next time? As we blunder through the Ebola crisis – a perfect storm of ignorance and inadequate healthcare – we must ask: If the education had been there or the healthcare infrastructure had been present or the international response had been more immediate, would this crisis be lessened? If all had been present, would the crisis be non-existent?
Action is being taken (to some, not nearly enough) to curb the spread of Ebola because the West is finally under threat. It’s no longer an African problem, but a global one. The final word belongs to Dr Murphy, as he puts so succinctly the take-home message of the Ebola crisis, “This is a wake-up call for the Western world to up its aid to resource poor countries to strengthen their health systems as it is in our own interest that emerging diseases (and there will be more) are quickly contained where they occur – and that will be in developing regions.”

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