Ebola Virus Disease (EVD). Formerly known as Ebola Hemorrhagic Fever (EHF). Currently enjoying its worst season ever (for people, not the virus) in West Africa, with over 800 infections and over 500 deaths in 100 days since March 23.

800 infections in 100 days doesn’t sound like much and I’m no epidemiologist. But surely the measure of control of an outbreak is the rates of new infections? Below is a graph based on the WHO Global Alert and Response (GAR) data. The simplest grasp of the graph shows that at this time, the virus is winning. And starting to win exponentially! Case in point – in the last 2 days, the total number of fatalities has risen by more than 10%. 31% of all deaths have occurred in the last two week. The outbreak was centered on Guinea, in a district immediately bordering Sierra Leone and Liberia. The borders are porous and the virus has spilled across them effortlessly. The disease has been confirmed over and area measuring 800km (500miles) by 500km (300 miles).

THe infection rates of ebola in west africa according to WHO data.

Medicin Sans Frontiers (MSF) is spooked, and has as recently as last week (July 4) described the virus as ‘out of control’. The World Health Organization (WHO) arranged a crisis meeting in Accra held in early July, which at this point has produced statements of conviction to combat the disease, a positive step.

To top it all off, this time Ebola has done something new and foreboding. The virus has managed to migrate from the remote jungle to cities. Cities like Conarky, Freetown and Monrovia. Cities with Airports. Cities with links direct to Paris and indirectly, through regional hubs like Accra, to North America, Europe, the Middle East and the rest of Africa. Where in the world can’t you get within 2 days of air travel (the suggested minimum incubation period of the virus)? Although with readily detectable symptoms occurring almost immediately, the idea of anyone from West Africa boarding a plane with a high fever seems pretty remote. However, today the news reports that a US expatriate  has died in a clinic near the airport in Accra, after travelling through two of the infected countries , of a fever-related disease that might have been Ebola, but isn’t (after four of five required tests). Reports saying that the results are uncertain persist in the media, particularly on the internet where the timing of the delivery of info is a bit scrambled).  It’s not hard to see how people get worried, or confused, or even a bit distrustful of what they’re hearing.

The confusion is justafiable about what the disease is. According to the CDC website, there are 16 hemorrhagic fevers, of varying severity. Unfortunately this one in Accra has proven fatal. But I wonder if he flew? I wonder if he had a fever as(if) he boarded the plane in a country with Ebola? If not, I wonder how long he was back in Ghana before becoming ill? And, of course,  while i’m glad it’s not Ebola, what did he die from!? Any fatal hemorrhagic fever has to be a bad one, whatever its called. In fact in January, a 12 year old girl died in Kumasi of a hemmorhagic fever that wasn’t Ebola either. Slim consolation.

Ebola virus has a 2-21 day incubation period. It has no cure and is fatal in 50-90% of cases (the current outbreak hovers around 60-65%). As it consumes you, it declares its presence by high fevers, vomiting, etc, almost immediately, and can lead to bleeding from the eyes, mouth and, fatally, from your internal organs (which is the ‘eurgh! factor that gets to me). The virus is spread amongst humans by direct contact with body fluids – blood, sweat or tears. It is normally hosted and transmitted amongst animals. Bats are the suspected main carrier – many colonies have antigens to suggest exposure to the virus at some point in the past, but other animals also carry the virus.

The good(?) thing about Ebola is that infected people get sick – really sick – fast. The reason this is good is that sick people don’t travel. Really sick people go to a hospital or a clinic or call a doctor. If a really sick person dies, isn’t there is a natural tendancy to isolate (or at least shy away from) other people with the same disease. Right? Not quite. Ebola is a disease which exploits the culture in West Africa. Traditions, conditions, development and history all conspire to assist the spread of the disease. Some of the factors and frustrations are as follows:

• Bush meat – animals that are trapped or hunted rather than farmed – is not an unusual addition to the diet in West Africa, there are no shortage of people selling various animals in various condition (live, dead, raw or cooked) on the side of the road. Obviously, there is absolutely no stigma attached to its consumption, bush meat has been on the menu since people first came here. Bush meat presents a perfect opportunity for Ebola to jump to humans.
  

  Bush meat can make you sick! Whoever would have thought…

• Traditional beliefs and customs include very close contact with the sick, dying or dead – another perfect vector for the disease.

• Traditional medicine (spiritual healers, fetish priests and more recently faith healers) are everywhere in West Africa, every village and community, no matter how remote. Despite the resounding success of christianity in West Africa, the paradox of mixed beliefs is real, particularly when something bad happens. Certainly, more educated people in larger towns are more likely to be skeptical of the traditional medicines and faiths, but you have to search pretty hard to find anyone who will flatly deny traditional beliefs or Juju – West African magic.

• The traditional beliefs have two negative effects. The first is that having an alternative treatment path impedes reporting, treatment and isolation of emerging outbreaks:
  “They have their traditional beliefs and their traditional cures and they look up to their traditional leaders. Until we can bring the traditional leaders onside, it will be very difficult to convince them that ebola even exists.” –ref. The second effect of traditional belief is, as stated in the quote above, that Juju is as conceivable a cause of the illness as a virus that suddenly sprung up on March 23. It’s perfectly logical position to take if it matches your version of reality. So there is a requirement to prove it is a disease to some communities.

• In West Africa, limited health care structures result in a stunning range of drugs being available over the counter. The possible result? Health services cannot neccessarily monitor or respond effectively, resulting in increased transmission as well as reactive (rather than proactive) disease control. In West Africa, this is apprently the case with people choosing to attempt stay at home rather than go to hospital, or to self medicate either through traditional medicing or over the counter drugs. This is exacerbated, again by limited communications.

• In conjunction with a uncertainty about the realities of the virus, there is a common (and unsurprising) questioning of the motives of government at all levels. West Africa has a long history of corruption, embezzlement, bribery, etc (If I was being cynical, perhaps a Ministry of Corruption (MoC) in some countries might increase transparency and accountability?) So, when government makes the clarion call for funding to fight an emerging crisis, the first thought of the masses is “What’s in it for you?”.

• And people are scared. Its easy to be rational when it’s all academic. I bet all the expats still in Ghana sat up and took notice when reports of a posssible case in Accra surfaced.

Once established in communities, the problems start to compound. West Africa is at best developing and at worst impoverished. Access to infected areas can’t be easy. Communication can be erratic. Organisation is frequently chaotic or poorly managed. Funding for public services (like health) may be sub-standard. For example, health workers have poor access to biohazard protective equipment and doctor to community ratios in parts of West Africa are 1:10,000.

One version of the spread of Ebola. Others include Freetown.

The WHO, manning the front line of various outbreaks like this, has guidelines for outbreak control . The cornerstone of an effective response? Page 1, point 1. Trust.

“The overriding goal for outbreak communication is to communicate with the public in ways that build, maintain or restore trust. This is true across cultures, political systems and level of country development.”

Is the trust in place? If a community is scared or in denial, and trust in the services or the intent of the groups attempting to help is not there – is the response more likely to be ‘covering up’ the issue?

Perhaps the NGOs that work to fill the voids in the structure and technical expertise are tarred with the same brush as the government organistions. There are reports of NGOs from Medicin Sans Frontiers (MSF) being driven out of areas by mobs as well as accusations that NGOs have brought the disease with them. Highlighting the frustration experienced while trying to isolate the outbreak, Liberia’s president has weighed into the discussion, reminding Liberians that ‘harbouring’ a person with Ebola can result in prosecution.

With poor communication and information flow, coupled with reported recalcitrance by the communities to fully cooperate in a fight against a disease they don’t necessarily believe in by governments and processes they don’t necessarily trust, the immediate questions might be:

How many more people really have the virus compared to the WHO data and haven’t entered the reporting system?

How do you manage an outbreak already spread over a couple of hundred thousand square kilometers?

How long, if at all, until Ebola steps to another country in the region? In Africa? Or elsewhere?

The tragedy here is that the disease reads like it should be easily controlled. There must be contact for its transmission. There is a relatively short incubation period and symptoms develop quickly, incapacitating the infected person…

…and yet a stunningly fatal virus is poised to rage through parts of West Africa.

[ a follow up post to this one, written a month later on August 2, can be found here]