Ebola

I have to admit, I haven’t paid much attention to the news on the Ebola outbreak in western Africa. It feels a long way away and I’ve had a lot going on closer to home which has meant my ability to, well, to put it bluntly, to care, has been limited.

But last week I went to a talk by a doctor from Médecins Sans Frontières (Doctors without Borders or MSF) which began to change that. I was invited by a friend and knew nothing in advance, but given the nature of the topic I was expecting a dry, statistics-filled talk. What we got was very different. The talk was by Dr Gabriel Fitzpatrick, Chairperson of MSF Ireland and it was a very much more personal and intimate talk than I anticipated. He had been working the previous month in Sierra Leone and described the work being done by doctors on the ground. It found it really interesting and thought there might be others who would also find it interesting.

The talk began by setting the scene. Ebola was first identified in 1976 and the current outbreak began in Guinea in December 2013. Since then it has spread to Liberia, Nigeria and Sierra Leone. The infection rate is doubling every three weeks and two-thirds of cases are treated by MSF yet there is no visible impact on the ground.

The current outbreak is being dealt with in the same, tried and tested way as other outbreaks. The focus is on getting infected people out of villages and into treatment centres in order to quarantine them and prevent transmission. Unfortunately, this isn’t as easy as it sounds.

The first problem comes from infrastructure. In the rural areas affected roads are generally little more than unsealed mud tracks. Vehicles frequently get stuck or overturn and there is no RAC so ingenuity and patience are required in vast amounts. Getting to villages requires a convoy of land rovers to carry the personnel and equipment needed to bring patients back, and, one would assume, to provide sufficient pushing power to free stuck vehicles. 

Road in Sierra Leone (Image from http://bit.ly/1vBnThr)

The next problem is more cultural. MSF staff enter these remote villages - a convoy of vehicles and then strange people speaking strange languages - get out and put on clothing that is incredibly intimidating to anyone. 

MSF doctor in full protection gear (image from http://bit.ly/1oFy7Hu)

Strangers aren’t always welcome and an element of diplomacy is required. The chief of the village is the first stop to ask his permission to check the populace for signs of Ebola. It is normal for ill people to be cared for by family members, making transmission almost inevitable and unfortunately the high likelihood of death from the disease means that MSF staff are effectively asking people to leave their families and die alone, away from their home and loved ones. This is a big ask but they are often successful as people recognise that while they are not going to be saved their sacrifice will save the lives of others.

The next step is to bring the infected people back to the treatment centres. The name is a bit of a misnomer as there is currently no treatment. They are more quarantine centres, trying to prevent transmission by removing infected people from the population. Those who are alive 13 days after admission have more than 90% chance of survival but 70% of those admitted die within 5 days. Age or sex makes no difference, though pregnant women inevitably die.

The treatment centres have a standard layout. 

MSF Treatment Centre (Image from http://bit.ly/1BCqHKZ)

There are two zones – high risk and low risk. In the low risk zone doctors and staff wear normal scrubs and there is little concern about infection. The high risk zone contains infected patients. In this area staff and visitors require personal protective equipment (PPE) which protects all their skin. Ebola is transmitted in body fluids – everything from vomit and faeces, to saliva and tears. Any contact with infected body fluids is potentially fatal so the PPE is extensive – no skin is visible and staff are paired so that they can check each other and ensure that they are safe at all times. Because staff are intimidating and anonymous in their gear they have their names written on their fronts so patients know who they are talking with. The PPE is extremely hot and staff don’t spend longer than an hour in it at a time. Reusable elements are carefully cleaned in a chlorine solution while disposable parts are incinerated.

The treatment centres are edged with orange see-through fencing. This is not because they can’t afford proper fencing, but to allow anyone who wants to see what’s going on inside – the work isn’t hidden or secret. It is a literal expression of transparency. It’s also important to note that patients aren’t forced to enter a treatment centre and once they are admitted they aren’t forced to stay. MSF doctors have no legal abilities, they work entirely on persuasion. That the treatment centres are overwhelmed with patients, to the extent they are having to turn people away, is a testament to their powers of persuasion.

Fencing at an MSF Treatment Centre (Image from http://bit.ly/1sPJ94c)

While the mortality rate is shockingly high and there is no cure, that’s not to say that patients are just put into quarantine and left to suffer and die. They are given anti-malarial drugs, broad spectrum antibiotics, pain relief and rehydration – oral or IV as required. This is all supportive care but it can be the difference between life and death, enabling those on the cusp to have the strength to fight the virus. Visitors (also in PPE) are allowed to visit and provide emotional comfort to those afflicted.

The funny thing about Ebola is that while it is highly infectious should you come into contact with it, coming into contact with it requires direct contact with body fluids. It is possible to be sat a couple of metres away from an infected person and not have any risk of infection. One of the reasons the outbreak has spread so far and fast is that cultural practices surrounding the dead mean that close contact is normal. People handle the dead at funerals and this allows Ebola to spread to family and friends of the deceased.

To try and prevent this transmission, cultural practices are being forced to change. Bodies are treated in ways that would have been horrifying to contemplate before the outbreak. They are screened off from other patients to try and hide the worst of the process but inevitably they realise what is going on. Clothing is removed and the body is washed in chlorine solution. They are then bagged and washed again, before being bagged again and washed for a final time. The bodies are then released to the family for burial. The intimate funerals where the bodies are animated by family members to enable a final goodbye are impossible to conduct but it appears that people understand that this is a necessary sacrifice to try and prevent further deaths.

For those who survive, blood tests show when they are cured. They are then free to leave the treatment centre and go home. Unfortunately, instead of being welcomed with open arms they are often ostracised. There is little follow-up on survivors and MSF admits there is not enough basic support but is trying to improve this. I got the impression staffing this support was the major issue.

It is important to note that while the foreign doctors often get most of the international kudos, 90% of staff are locals. While foreign doctors are able to leave after a month’s rotation to go home and recuperate after their stressful, emotional and very intense work, local doctors and support staff don’t have that luxury. And while foreign doctors have the knowledge that should the worst befall and they get infected, they will be whisked away to a hospital in their own country and given the best treatment possible, local staff will just end up in the same treatment centre they are working in. As of the time of the talk, 14 staff had been infected of whom eight have died.

The current outbreak is unprecedented. More have died than have died in all the previous outbreaks combined. The precise numbers are difficult to obtain due to the remoteness of many of the infected areas, the number of different agencies involved who have different recording methods and who don’t always communicate well with each other, and the speed at which the outbreak is spreading. This speed is why MSF are requesting military intervention. While this is not a situation where the military option is obvious, the reasoning is sound. MSF are overwhelmed. The treatment centres work but they don’t have the manpower to build and staff the numbers required in the regions that need them quickly enough to be effective. What they need are groups with good organisation and leadership, used to working in tough environments and have biohazard capabilities. This skillset is held by the militaries of several countries and hopefully they will rise to the occasion and take on this humanitarian mission.

The talk was really interesting and brought home the fact that this was people who were suffering and dying, it's not an abstract thing. There are people right now lying in pain wondering if they will make it to tomorrow, families being torn apart by this disease - children losing parents and siblings, parents losing children and partners. It may not be possible in this outbreak to reduce the mortality rate significantly, but we can reduce the rate of infection by giving MSF the resources it needs to stem the tide of transmission. They have the experience and expertise, they now just need the manpower to implement it on a large enough scale to be effective.

If you have any spare cash I’d urge you to donate to msf.org.uk. Less than a pound can buy a protective mask, a fiver can buy a protective apron and a tenner a pair of protective boots. This outbreak shows no signs of stopping without significant intervention. Despite the news of a case in the US recently, there is little reason to worry about it spreading out of Africa. But in Africa it is killing people and that should be reason enough to intervene.