Above: Protective gear drying in the sun after disinfection. The virus can be transmitted through contact with any bodily fluid and medical workers are frequently some of the first victims of the virus due to a lack of protective gear in under-equipped rural clinics. (Image Courtesy: SEYLLOU / AFP / Getty Images / April 1, 2014)
It is difficult to imagine a virus much more terrifying than ebola. The infection boasts a fatality rate that can top 90%, has no known cure, and causes gorey symptoms like severe internal and external hemorrhaging. When we read or hear about ebola in the news, it is easy to imagine worst case scenarios, like a devastating global pandemic à la Contagion. Fortunately, we can feel secure in the fact that this risk is highly unlikely, given that surveillance systems in place in most parts of the developed world are capable to finding and isolating such dangerous health threats quickly. Despite the low risk of pandemic, the voracity of the ongoing outbreak in West Africa is certainly worrying for the region, as control efforts seem to be having little impact on the spread of the infection in these areas. Without the availability of a vaccination or a cure, the only way to control the spread of the virus, which is transmitted through contact with bodily fluids, is to find and isolate all potential cases and contacts.
This is much easier said than done, as tracing cases and contacts requires the intensive collaboration and unwavering commitment of health ministries, international medical organizations, and, most critically, the local population. In the case of the West African outbreak, these time-consuming and resource intensive control efforts have been hampered by a combination of unique regional characteristics, high prevalence of poorly-equipped health systems, and a deep division between the need for critical control methods and the persistence of local customs and beliefs.
The first confirmed case in the West Africa outbreak was reported in southern Guinea in February. Since then, the virus has continued to spread unabated though areas of Guinea, Sierra Leone, and Liberia and sparked fears of broader international transmission in the surrounding region. Morbidity has been devastatingly high in this outbreak, with the fatality rate hovering around 60%. So far, close to 900 people are known to have been infected and 539 have died, making the West African outbreak the most deadly ever recorded and also the largest in terms of geographical spread. Since February, over 60 ‘hotspots’ of infection have been identified throughout the 3 afflicted countries.
What makes this outbreak so hard to control? First, unlike other Ebola outbreaks, which have typically occurred in remote areas of Central Africa, far from international borders, this outbreak is unique in that it presented in a region with a high density of well-travelled transit corridors and porous international borders. These characteristics have provided the virus an opportunity to easily and covertly infect new areas and has significantly complicated the response process as three governments, rather than one, need to collaborate in order to provide a swift and unified response. Compounding these difficulties, the three affected nations are among some of the poorest nations in the world.
The deadly impacts of this rapid transport of the virus and complicated international collaboration efforts were further magnified by the poorly equipped health systems of this resource-limited region. Before February, West Africa had never experienced an Ebola outbreak and, as such, the region’s already overburdened clinics lacked the experience and the equipment necessary to diagnose and then safely provide care for victims of this rare and highly virulent disease. Sadly, during ebola outbreaks, medical staff are frequently some of the first victims because they come into close contact with the body fluids of infected people while providing care. In the case of this outbreak, too much time passed before ebola was finally clinically confirmed in Guinea and medical staff were introduced to hygienic protocols designed to reduce the risk of transmission. Even then, many clinics still did not have the necessary resources to follow these protocols, resulting in the loss of additional lives and the further spread of the virus.
Widespread misinformation, distrust, and fear associated with ebola and the control teams charged with eliminating the virus have proven to be the most serious challenges in the control of this epidemic. Local beliefs and superstitions are widespread and counter scientific knowledge of the virus and how it is transmitted, with many locals not believing that ebola is real or even dangerous. Others believe that the disease is the result of curses or witchcraft and choose not to follow strategies to reduce the risk infection.
To make the situation more complicated, medical teams outfitted in hazmat-like protective suits must go door to door in communities to search for potential cases and trace contacts. This experience can be traumatizing for families because after a potential case is found, they are taken away to an isolation unit. The lack of a cure means that the infected person will likely succumb to his or her infection. After death, the body and materials it has come in contact with remain a potential source of infection and, for this reason, the corpse must be immediately disposed of, without ceremony, to prevent further infection.
In a region with long-held rituals regarding the care of the sick and preparation of the body of the dead for burial, this seemingly callous approach has even sparked widespread rumors of body part selling and murder. In some cases, distraught families have resorted to hiding ill family members, fearful to allow medical teams to take them away to the isolation units, likely never to be seen again. Others have retrieved their sick family members from these isolation units. At least 57 cases of hospital disappearances have been reported so far. In other cases, family members have stolen the bodies of family members after their burial by control teams in order to wash the body and perform last rites according to local custom. In doing so, the virus has continued to spread and the mistrust and fear has only intensified, despite attempts by medical teams to increase awareness about the infection. In recent weeks, this fear has culminated in anger and violence in some communities. Last week, a car carrying medical workers was surrounded by an angry crowd brandishing knives and forced to leave. In an another event, an angry crowd destroyed a bridge leading into their community to prevent a medical team that was searching for potential cases from entering.
In the case of the West Africa outbreak the challenge has clearly become, as with other diseases control programs, finding a way to balance local population needs while simultaneously carrying out the essential control strategies. However, finding this balance will likely become more difficult, as tensions continue to build. According to the WHO Assistant Director of Health Security, there is not a quick end in sight in the case of the West Africa outbreak. The complete interruption in transmission will likely take several months and require continued intensive collaboration on the parts of regional governments and international medical aid organizations to raise awareness among the at-risk populations about the realities of the virus to encourage the swift reporting of cases and, also, coordinate the adoption of more culturally sensitive strategies for detecting cases and burying victims by control teams.
Most importantly, after the final case is reported, the work is not complete. Ebola leaves communities with crippled health systems and devastated economies. Among populations already overburdened by diseases of poverty, after struggling to survive the grip of ebola, the exposure to infectious killers is riskier than ever. The ongoing collaboration between governments and major organizations during the course of the West Africa outbreak provide a unique opportunity to spotlight major health issues and create a unified plan for a healthier future. In such highly vulnerable areas targeted investments in the prevention of ebola and other diseases of poverty must become a mainstream priority.
-Olivia Johns-Yost; Research Officer