Oct 19: Ebola crisis and inequality

October 19, 2014

http://zcomm.org/znetarticle/diary-2/

Diary

Paul Farmer

I have just returned from Liberia with a group of physicians and
health activists. We are heading back in a few days. The country is in
the midst of the largest ever epidemic of Ebola haemorrhagic fever.
It’s an acute and brutal affliction. Ebola is a zoonosis – it leaps
from animal hosts to humans – which is caused by a filovirus (a
thread-like virus that causes internal and external bleeding). It was
first described in 1976 in rural Congo, not far from the Ebola River,
as an acute-onset syndrome characterised by complaints of weakness,
followed by fever and abdominal pain. Patients became dehydrated as a
consequence of fever, vomiting and diarrhoea. Many became delirious
and started to haemorrhage from the mouth, nose, vagina, at sites
where intravenous lines had been placed, even from the eyes.

The Ebola virus is terrifying because it infects most of those who
care for the afflicted and kills most of those who fall ill: at least,
that’s the received wisdom. But it isn’t clear that the received
wisdom is right. It’s true that many of those who have died were
medical professionals. The 1976 epidemic, for example, started in a
mission hospital where Belgian nuns worked as nurses alongside
Congolese colleagues. But even then it was known that the virus could
be transmitted as the result of a failure to follow the rules of
modern infection control: the nurses reused needles and did not wear
gloves, gowns or masks, which were all in short supply. Nor did the
nurses, still less their patients, receive what in Brussels, Boston or
Paris would count as modern medical care.

Even without a specific antiviral therapy, the treatment for
hypovolaemic shock – which occurs when there isn’t enough blood for
the heart to pump through the body and is the end result of many
infections caused by bacteria and some caused by haemorrhagic viruses
– is aggressive fluid resuscitation. For those able to take fluids by
mouth, shock can often be forestalled by oral rehydration salts given
by the litre. Patients who are vomiting or delirious are treated with
intravenous fluids; haemorrhagic symptoms are treated with blood
products. Any emergency room in the US or Europe can offer such care,
and can also treat patients in isolation wards.

Both nurses and doctors are scarce in the regions most heavily
affected by Ebola. Even before the current crisis killed many of
Liberia’s health professionals, there were fewer than fifty doctors
working in the public health system in a country of more than four
million people, most of whom live far from the capital. That’s one
physician per 100,000 population, compared to 240 per 100,000 in the
United States or 670 in Cuba. Properly equipped hospitals are even
scarcer than staff, and this is true across the regions most affected
by Ebola. Also scarce is personal protective equipment (PPE): gowns,
gloves, masks, face shields etc. In Liberia there isn’t the staff, the
stuff or the space to stop infections transmitted through bodily
fluids, including blood, urine, breast milk, sweat, semen, vomit and
diarrhoea. Ebola virus is shed during clinical illness and after
death: it remains viable and infectious long after its hosts have
breathed their last. Preparing the dead for burial has turned hundreds
of mourners into Ebola victims.

Many of the region’s recent health gains, including a sharp decline in
child mortality, have already been reversed, in large part because
basic medical services have been shut down as a result of the crisis.
Most of Ebola’s victims may well be dying from other causes: women in
childbirth, children from diarrhoea, people in road accidents or from
trauma of other sorts. There’s little doubt that the current epidemic
can be stopped, but no one knows when or how it will be reined in. As
Barack Obama said, speaking at a special session of the United
Nations, ‘Do not stand by, thinking that somehow, because of what
we’ve done, that it’s taken care of. It’s not.’ Preventing the next
eruption is an even more distant goal.

As of 1 October, a third of all Ebola cases ever documented were
registered in September 2014. More than seven thousand cases have been
recorded since March, more than half of them fatal. In epidemiological
terms, the doubling times of the current Ebola outbreak are 15.7 days
in Guinea, 23.6 days in Liberia and 30.2 days in Sierra Leone. The US
Centers for Disease Control and Prevention suggested at the end of
September that unless urgent action is taken, more than a million
people could be infected in the next few months.

The worst is yet to come, especially when we take into account the
social and economic impact of the epidemic, which has so far hit only
a small number of patients (by contrast, the combined death toll of
Aids, tuberculosis and malaria, the ‘big three’ infectious pathogens,
was six million a year as recently as 2000). Trade and commerce in
West Africa have already been gravely affected. And Ebola has reached
the heart of the Liberian government, which is led by the first woman
to win a presidential election in an African democracy. There were
rumours that President Ellen Johnson Sirleaf was not attending the UN
meeting because she was busy dealing with the crisis, or because she
faced political instability at home. But we knew that one of her staff
had fallen ill with Ebola. A few days ago, we heard that another of
our Liberian hosts, a senior health official, had placed herself in
21-day quarantine. Although she is without symptoms, her chief aide
died of Ebola on 25 September. Such developments, along with the rapid
pace and often spectacular features of the illness, have led to a
level of fear and stigma which seems even greater than that normally
caused by pandemic disease.

But the fact is that weak health systems, not unprecedented virulence
or a previously unknown mode of transmission, are to blame for Ebola’s
rapid spread. Weak health systems are also to blame for the high
case-fatality rates in the current pandemic, which is caused by the
Zaire strain of the virus. The obverse of this fact – and it is a fact
– is the welcome news that the spread of the disease can be stopped by
linking better infection control (to protect the uninfected) to
improved clinical care (to save the afflicted). An Ebola diagnosis
need not be a death sentence. Here’s my assertion as an infectious
disease specialist: if patients are promptly diagnosed and receive
aggressive supportive care – including fluid resuscitation,
electrolyte replacement and blood products – the great majority, as
many as 90 per cent, should survive.

Ebola’s more general effects also damage the effort to treat the
disease. The closure of national borders means, among other things,
that it’s more difficult for the staff and the stuff to reach those
most in need. Many airlines have halted services. Schools have been
shut down, including medical and nursing schools. Food and fuel, much
of it imported, are becoming scarce. Exxon has announced that it is
delaying offshore drilling plans. Supply chains have been cut off.
Hospitals and clinics have been closed.

There have been incidents of violence linked to fear and stigma. In
Liberia – where we were warmly welcomed – my colleagues and I heard
that seven Ebola workers, apparently including two local public-health
officials, had been murdered with machetes in rural Guinea. Their
bodies were discovered in the septic tank of a local primary school.
Eleven years ago, four Congolese schoolteachers engaged in
Ebola-awareness campaigns were also killed. The complex relationship
between contagion, lethality, stigma and long neglect – most people in
rural West Africa have never had access to comprehensive medical care
– has yet to be laid out.

I’ve been asked more than once what the formula for effective action
against Ebola might be. It’s often those reluctant to invest in a
comprehensive model of prevention and care for the poor who ask for
ready-made solutions. What’s the ‘model’ or the ‘minimum basic
package’? What are the ‘metrics’ to evaluate ‘cost-effectiveness’? The
desire for simple solutions and for proof of a high ‘return on
investment’ will be encountered by anyone aiming to deliver
comprehensive services (which will necessarily include both prevention
and care, all too often pitted against each other) to the poor. Anyone
whose metrics or proof are judged wanting is likely to receive a cool
reception, even though the Ebola crisis should serve as an object
lesson and rebuke to those who tolerate anaemic state funding of, or
even cutbacks in, public health and healthcare delivery. Without
staff, stuff, space and systems, nothing can be done.

If such things were thin on the ground in Monrovia and Freetown, they
were all but absent in rural regions. Zwedru is the capital of Grand
Gedeh County in south-eastern Liberia, a region mostly covered by
rainforest. Flying from Monrovia to Zwedru reminds you how vast and
green – and rainy – much of the country is, especially in September.
Outside the capital, paved roads are as scarce as electricity: in
2013, it was estimated that less than 1 per cent of Liberia was
electrified. As Sirleaf recently pointed out, the Dallas Cowboys
football stadium consumes more energy each year than the whole of
Liberia. It is very difficult to take care of critically ill patients
in the dark; fluid resuscitation depends on being able to place and
replace intravenous lines.

In Zwedru, we visited the Grand Gedeh’s only hospital. Although there
have been stories of doctors and nurses fleeing their posts, the fact
is that many remain. But without personal protective equipment or
other supplies, there isn’t a lot they can do. We didn’t see any Ebola
patients in the hospital. Rumour had it that the hospital
administration had just sent away a carload of suspects. In Ziah Town,
a small village a couple of hours away, we met some community health
workers. They were a well-informed group of mostly young men and
women. Kru was their native language; they spoke English just fine.
They were the front line in the struggle against Ebola, the ones who
could bring information and services to the rural poor. But they were
isolated and badly equipped. The sun beat down on the immense forest
and the dirt roads cutting through it. We were slated to leave
Monrovia the following afternoon. Thunderheads blackened the eastern
sky, and it wasn’t clear we’d make the plane; the four-wheel-drive
vehicles were having a hard time. Stuck in the mud, we wondered how
the community health workers would be able to get sick patients to
Ebola care centres, a series of planned but not yet constructed
halfway houses.

Although the Grand Gedeh had been declared Ebola-free, it was also
free of diagnostic tests. And electricity and surfaced roads. But the
community health workers, like the people in Ziah Town, were plugged
into the cash economy: people had cell phones (if little signal) and
wore T-shirts (one of them emblazoned with the shield of a small
Midwestern college); children were kicking a football around; one boy
was nursing a can of Red Bull. ‘How do they make a living?’ I asked
one of the young American volunteers. She hesitated, although she’d
lived and worked in Zwedru for more than a year. ‘They’re great
hunters,’ she said. After listening patiently to our halting
conversation, the driver of the jeep – we were waiting for our convoy
to emerge from the mud – helped out. He was from Monrovia, he said.
He’d been working in the Grand Gedeh for more than ten years, first as
an officer in the disarmament programme, and then as a driver and
logistician. ‘It’s not just hunting and small-scale farming,’ he said.
There were also mining, remittances from abroad and international
trade. Many of the shopkeepers in town were from Guinea, Sierra Leone
or Côte d’Ivoire. It may have looked like isolated rainforest, but the
place is connected to the rest of West Africa.

That means it’s connected to the rest of the world too. And however
the epidemic started – whether through the ingestion of bush meat or
an infected bit of fruit dropped by a clumsy fruit bat – it’s clear
enough that attempts to seal national borders won’t stop it. There are
no checkpoints or barriers in the forests. The day when enclosure
might have worked is long gone. A CNN interviewer asked me if Ebola
might spread to Europe and North America. ‘Of course it will,’ I
replied. ‘We live in a global economy.’

On 30 September, the US Centers for Disease Control and Prevention
confirmed the first diagnosis of the disease in the United States. A
traveller from Liberia, asymptomatic (by self-report) on boarding a
flight from Monrovia to the United States on 19 September (as our team
left Zwedru for Monrovia), fell ill in Dallas a few days later. His
symptoms were similar to those described in every Ebola case: a fever
of 40°C, weakness, abdominal pain. He had a history of exposure,
having driven a young woman, pregnant and bleeding, to a hospital in
Monrovia; she was turned away and later died. But on his first visit
to an emergency room, his symptoms were judged ‘non-specific’ and the
diagnosis was missed even though he had come from Liberia. Two days
later, highly infectious and critically ill, he was taken by ambulance
back to the same hospital and admitted to intensive care. Within
hours, the cause of his illness was confirmed as Ebola, Zaire strain.
He is now dying. It’s unlikely that the American subplot is over. The
cycle of fear and stigma, amped up by the media, will continue to
spiral, even though there’s little doubt that the epidemic will be
contained in the US, which has the staff, stuff, space and systems.

Ebola is more a symptom of a weak healthcare system than anything
else. But until this diagnosis is agreed on, there’s plenty of room
for other, more exotic explanations. The palaver (as Liberians say)
includes a lot of talk about the ‘cultural beliefs and behaviours’
said to propagate the outbreak. The list usually includes activities
that are not really ‘behaviours’, such as hunting and eating bush
meat, taking part in strange funerary practices or the bizarre rituals
of ‘secret societies’ like the Poro or the Human Leopard Societies. An
obsession with funerary rituals – the more lurid the better – was
characteristic of anthropology from the late 19th century on. Tribes
of the Liberian Hinterland (1947), written in the passive voice and
matter-of-fact tone typical of the genre, contains more than five
hundred pages of this sort of stuff:

Formerly, only chiefs and big men were washed after they died. In
Half-Grebo the corpse of a warrior who died from the effects of a
gunshot wound was taken to a stream and washed. In both Grebo and
Sapa, the shot was extracted in order to prevent his being
reincarnated with a wound.

Now, all the dead are washed. The corpse is then laid on a mat and
rolled up in it. With the corpse are put some cloths, the number
varying with the rank of the person.

Despite anthropologists’ fondness of recounting such practices, these
rites are not suspected of having played a major role in outbreaks of
Ebola in Congo, Uganda and Sudan over the last forty years. The
inhabitants of coastal West Africa have eaten bush meat for centuries
and they have prepared the dead for burial without taking precautions
to stop transmission of a pathogen like Ebola. Even so, it isn’t
improbable that these practices helped to spark and then fan this
outbreak, which began in the Upper Guinea Rainforest.

What accounts for Ebola’s spread from Guéckédou to Monrovia and
Freetown and now to Dallas? As Larry Brilliant, who helped to
eradicate smallpox almost forty years ago, just as Ebola was being
discovered, and now heads the Skoll Foundation’s Global Threats Fund,
has observed, ‘Outbreaks are inevitable. Pandemics are optional.’ The
eating of bush meat can’t possibly explain the epidemic, but grotesque
and growing disparities in access to care – in the context of a
globalised political economy – can. The attempt to treat Ebola
patients in a weak health system – or at home – has been strongly
linked to the transmission of the virus. In several West African
hospitals, Ebola has ripped through the professional staff: health
professionals, nurses’ aides, morgue attendants. Understaffed and
undersupplied, front-line health workers in West Africa have good
reason to be afraid. We who aim to help them, though better equipped,
are afraid too.

The others at great risk, obviously enough, are the primary caregivers
of the sick: not health professionals but family members, especially
women. Associated Press reported the story of a 14-year-old Liberian
boy: ‘Too weak to stand, they bundled him into a taxi with his
backpack and a yellow plastic bucket for his vomit … “He’s been sick
for a week with a runny stomach,” says his distressed mother, wiping
the sweat off the boy’s brow with bare hands. “We tried calling an
ambulance days ago, but nobody ever came.”’

Who will come when we call? Who will show up not just if it’s
convenient or cost-effective or already budgeted? It isn’t clear that
all such responsibilities should be handed out to contractors or NGOs.
The three countries most afflicted by Ebola are those with some of the
lowest public investment in healthcare and public health in Africa.
They have been wracked by war, and by extractive industries, which
have never failed to turn a profit. This is one of the reasons that
Liberia could boast, only a few years ago, the fastest growing GDP in
the world.

For most of a century, the Firestone Rubber Company has been the
largest taxpayer in Liberia. In 1926 it negotiated a million-acre
concession at six cents an acre, for ninety years. By the Second World
War, there was a little bit of the Liberian forest in many, if not
most, American cars. Firestone is still in Liberia. It promised
350,000 jobs, but never created more than a quarter of that number.
For decades, plantation workers demanded better pay, a high school and
medical care. In recent years, they achieved some measure of success.
But the epidemic has affected them too. At the end of March, the wife
of a Firestone employee left Lofa County, which borders Guinea, not
far from where the first case was recorded. She had a sudden-onset
generalised weakness and fever. Eight times out of ten, the pathogens
responsible would be those that cause malaria, pneumococcal pneumonia,
typhoid fever, influenza or a complication of Aids. Lassa, another
haemorrhagic fever, would be on the list in Liberia, but Ebola was
then unknown in the region. On 31 March, the woman travelled by taxi
to Monrovia with five other passengers, including her infant, but was
referred back to the Firestone plantation, to Duside Hospital. By
then, sick with profuse diarrhoea and vomiting, she was diagnosed with
Ebola. She continued to lose vital fluids and electrolytes, and
slipped into hypovolaemic shock. As her blood pressure dropped, nurses
did their best to resuscitate her. Within an hour, it was all over.

Except that it wasn’t. Four months later, 72 cases of Ebola were
diagnosed in rapid succession at Duside; only 18 patients survived.
Yet the Firestone response was considered a success, since infection
control was improved during those months and transmission within the
hospital declined rapidly.

Such back and forth is how Ebola got to the city and into its clinical
facilities. St Joseph’s Catholic Hospital, in a Monrovian slum, has
lost many of its caregivers and most of its patients. Within two weeks
of its first cases, the hospital director fell ill with similar
symptoms. This time, they knew what was coming. But even for its most
valued professionals, the hospital could not conjure proper medical
care out of nothing. Two more nurses, two laboratory technicians and a
social worker were all dead within a couple of months of the city’s
first two cases. So too were several of the nuns and priests working
there. Father Miguel Pajares was airlifted home to Spain; so, later,
was Father García Viejo, working in a small town in Sierra Leone. Both
died in Madrid. It is unlikely that we have heard the last from Spain
either.

What is to be done? The only formula we’ve come up with is the
following: you can’t stop Ebola without staff, stuff, space and
systems. And these need to reach not only cities but also the rural
areas in which most people in West Africa still live. First, we need
to stop transmission. The source of the first human cases is no longer
the primary concern. Transmission is person to person, and in the
absence of an effective medical system, it occurs wherever care is
given: in households, clinics and hospitals, and where the dead are
tended. Infection control must be strengthened in all of these places,
and during burials, which requires not only training and exhortations
(which are already given in cities throughout West Africa, on
billboards and radio, and in community meetings) but also
uninterrupted supplies of personal protective equipment. Community
health workers, too, need to be better equipped, trained and paid if
they are to play a role in contact-tracing and early diagnosis, as
well as trying to address the mounting number of deaths caused by
other conditions.

Second, we need to avoid pitting prevention against treatment. Both
are necessary. Adam Levine helped to open the first Ebola Treatment
Unit in Bong county, Liberia, after working in an ETU in Monrovia. An
emergency medicine specialist, he describes what it feels like to be
working without the right therapies, while wearing a stifling shroud:

On my third day of training, I come across an older man, also lying
motionless on his mattress. At first I think he might be dead, but as
I lay my double-gloved hand gently on his shoulder, he turns his head
to look up at me. His eyes are sunken and his lips parched, his skin
flattening only slowly when pinched. He is severely dehydrated from
the profuse diarrhoea common with Ebola. Usually a drip of intravenous
fluids would be started, but the [ETU] lacks sufficient staff to
safely place intravenous catheters for patients. So instead I turn the
patient slowly onto his back, grab the full bottle of oral rehydration
solution lying by his side, and pour a tiny capful into the man’s
slightly open mouth. Surprisingly, he swallows it. I pour another
capful, and then another, and he keeps swallowing. Only a few hundred
more capfuls to rehydrate him, but I know that in the stifling heat I
am not going to last much longer in my full PPE.

Most experts don’t think staff should spend more than two or three
hours in PPE. Dizzied by heat, even the most cautious professionals
start to make mistakes.

Equality of access to care is important if we are to encourage the
sick into quarantine. Two weeks ago, a Liberian physician told me a
story I won’t soon forget. He and some Liberian and Ugandan colleagues
were planning on opening an ETU in Monrovia after the other clinics
had stopped giving intravenous fluids; patients were dying of
untreated shock. When one of the European caregivers at his ETU fell
ill and was about to be airlifted home, the ETU director asked him to
find an infusion pump. He spent hours looking, and eventually found
one, but not before the non-national was airlifted away. She survived.

Third, the rebuilding of primary care must be informed by what has
been learned from the response to this outbreak. The hospital we
visited in Zwedru, which has 140 beds, was technically open; staff,
including the sole attending physician, were present. But there
weren’t many patients in the wards, or outpatients. The pharmacy had
no drugs or supplies, including PPE. The laboratory was short of
reagents; the recently donated digital radiography unit hadn’t been
installed because there weren’t any batteries. There was no infection
control, which was why the five Ebola suspects had been sent away (two
of them died shortly afterwards of confirmed Ebola).

Fourth, the knowledge gained from the response must be built on. Every
attempt to prevent the spread of Ebola should involve proper care for
quarantined patients. Even without a vaccine or Ebola-specific
therapies, it’s possible to imagine this bringing a marked drop in
case-fatality rates. But we need specific therapy, better and faster
diagnosis, and effective vaccines. The vaccines and drugs required to
treat so-called ‘emerging infectious diseases’ do not exist because of
what James Surowiecki has called ‘Ebolanomics’. ‘When a disease’s
victims are both poor and not very numerous,’ he says, ‘that’s a
double whammy. On both scores, a drug for Ebola looks like a bad
investment.’ The Onion recently ran the headline: ‘Experts: Ebola
vaccine at least fifty white people away.’

It needn’t be this way. Several vaccines are ready for clinical
trials; a number of treatments – including ZMapp, a combination of
monoclonal antibodies developed by a pharmaceutical and a biodefence
company, and RNA interference agents – are also ready for trial. The
process should be fast-tracked, and willing Ebola survivors (who
should be immune) recruited by the thousand into this work as well as
into providing clinical care.

Fifth, formal training programmes should be set up for Liberians,
Guineans and Sierra Leoneans. Vaccines and diagnostics and treatments
will not be discovered or developed without linking research to
clinical care; new developments won’t be delivered across West Africa
without training the next generation of researchers, clinicians and
managers. West Africa needs well-designed and well-resourced medical
and nursing schools as well as laboratories able to conduct
surveillance and to respond earlier and more effectively. Less
palaver, more action.