The current outbreak in West Africa is estimated to have consisted of at least 2,400 cases so far, more than every other outbreak since the virus’s discovery combined. The geographic scale too, is unprecedented. Where previous outbreaks have affected at most a few villages in remote areas, the current outbreak has expanded from its rural beginnings to cover most of Sierra Leone and Liberia, including the capital cities, as well as much of Guinea. Although this was unexpected, it is explicable.
The uncontrolled transmission of the virus has been facilitated by a variety of factors that are to some extent unique to the region. Funeral rites in many communities involve families bathing the dead before burial, with potentially fatal consequences when the cause of death has been a highly infectious pathogen, which is secreted in bodily fluids. Such pathogens are rare – with few exceptions (cholera and typhoid spring to mind), there is no comparable risk from bathing the bodies of those who have died of other infectious diseases.
Like DR Congo, where the virus is endemic, health systems in the effected countries have been weakened by prolonged conflict and extreme poverty. Sierra Leone was, until recently, the poorest country in the world. In addition, because the virus was previously unknown in West Africa, health workers were unprepared. There are few pathogens that present such a risk in a hospital setting – ebola is in almost every form of excreta. The symptoms commonly include vomiting and diarrhoea, in addition to the less common but very recognisable bleeding. Health workers who aren’t using the right protective equipment in exactly the right way will inevitably be exposed to the bodily fluids of their patients. The right protective equipment and the knowledge of its correct use was not present in these settings, because the virus was previously unknown there. MSF has reported incinerating thousands of dollars worth of equipment from its facilities each day, because so little can be decontaminated and reused. Public health facilities in these countries do not have those kind of resources. Many of the victims of the current outbreak have been health workers, and many of their colleagues are now too afraid to go to work, further weakening health systems, now on the point of collapse.
The impact of this last development is likely to escalate. It is the middle of the rainy season. Malaria, which is endemic, has non-specific symptoms which mimic ebola in its early stages – high fever, vomiting. The prevalence in Sierra Leone is among the highest in the world. Hundreds of thousands of people will experience malaria in these countries in the next few months – those who need medical attention must be differentiated from ebola patients, housed separately if admitted to hospitals, and treated without being exposed to ebola through contaminated medical equipment or contact with staff doing double duty. Ebola is currently consuming literally 100% of all health resources in some affected areas – at least one man has already died from malaria after being turned away from a health facility. Health care providers, including NGOs, face Sophie’s choice: do they spend all available resources on attempting to get the outbreak under control, knowing that malaria patients, women in labour, and children with other diseases will die, or do they attempt to do both, knowing that this will weaken ebola control efforts? Currently, ebola control is taking priority.
Finally, knowing what they do about the state of the health system, patients are not presenting to clinics. Families are hiding their loved ones in their homes and attempting to care for them. Many people still refuse to believe that Ebola is in the country at all, claiming that this is merely a government ploy to extort aid money from foreign donors. Sick people are remaining hidden in the community, and the people who care for them and then bury them are becoming exposed themselves. Extended families are being decimated in a matter of weeks. Survivors will acquire immunity, but survivors are few. Without medical intervention, the fatality rate is as high as 90%. With appropriate care, it is less than half that.
What is so tragic in this outbreak is that the appropriate care is so simple. Although the virus cannot be cured, just providing IV fluids and controlling fevers very easily saves lives. This is why ebola effectively presents no threat to high resource countries: easy access to health services, combined with adequate infection control procedures and the high standard of care available, is sufficient to prevent onward transmission. This is not HIV – there is no need for million dollar drugs and lifelong care. That Guinea, Liberia and Sierra Leone lacked the resources to control a disease which is, in theory, so easily controlled, is a travesty. If Nigeria in turn is unable to control the current, limited chain of transmission in Lagos, Africa’s largest city, it will be a catastrophe. MSF, WHO and others are engaged in a Herculean effort to provide the resources and training necessary to stop transmission in the next six to nine months. The World Bank has pledged US$200 million for the effort, an almost unheard of commitment. What will be done about malaria is less clear. The combined death toll of both diseases will continue to rise until patients are willing and able to access health services, and until those services can actually treat them without facilitating onward transmission.
After the crisis is over, the recovery of the health systems in these countries will be slow – they did not have the staff to lose. Training new staff to replace those who have died will take years, and cost millions. The WHO has articulated an intention to walk away not when the last ebola patient has been treated, but only when the health system itself has recovered. This commitment must be honoured, both by the WHO and the international community more broadly. These countries must not be left like Haiti – devastated by a crisis which, although not preventable in itself, was massively exacerbated by already unacceptable conditions on the ground. That these countries were so vulnerable should ultimately draw our attention to something much bigger than the virus.