Anahita Sharma reviews an educational event – Ebola: Beyond the Headlines – that featured two speakers, Dr. Cox-Singh, and nurse from Médecins Sans Frontières, Gunnhilder Arnadottir.
“While devastating in its impact, the real enemy is not the Ebola virus or the animals from which it emerges. Whether on a local level in regions affected by the outbreak, or through the international media, ignorance and fear are our true adversaries.” 
What’s in the public eye?
Dr. Cox-Singh, an incredibly personable molecular biologist and malaria researcher by trade, drove us down South Street that evening. Here we were in St Andrews – a thought that has passed through many minds – feeling ‘a world away’.
I speak only for myself. As a medical student with an interest in global health inequities, I was aware of the Ebola virus’ pathological manifestations, and aware that this was a particularly virulent form – one that had made the powerful leap into the human host, an animal in which it wreaks devastating effects. Yet, at that moment, months into the epidemic, I had succeeded in remaining utterly oblivious to what was actually going on. I simply could not figure this one out.
I sat next to her, hoping for nothing more than informed illumination on the unquenchable darkness surrounding the epidemic. As she had dived through medical literature and consciously avoided bias, this was precisely on offer. As the evening transpired, it seemed that the hyperbole and chaos of mainstream media narratives, rather than accurately characterising the disease, was more accurately reflecting the chaotic and distressing nature of the on-the-ground situation. This article is dedicated to the individuals and families affected by the virus, and for those mobilising against it.
The sight of hundreds of students queuing for an educational awareness event co-hosted by ‘Medsin’, ‘Friends of Medecins sans Frontieres’, The Economic Society, and The Foreign Affairs Society, held an element of surprise. This was a considerably larger audience than has ever been attracted to any other large-scale and, I would also argue, equally serious, global health problem we have previously placed a magnifying lens upon. This particular one was touching several nerves in Parliament Hall: mine, because the power of tapping into public uncertainty immediately became self-evident; secondly, those of the speakers, whose accounts and perspectives revealed strength, frustration, and helplessness; and finally, of course, those of the audience.
Why this coincidence of strength and helplessness? With brevity: the solutions do actually exist. The ‘global health’ field deals with the sloppiest structural problems faced by every healthcare system in the world, which prevent healthcare workers from being able to look after patients to their best capacities. It attacks the unique healthcare needs of every population. It addresses resource allocations and deficiencies in access to basic healthcare. It recognises the relationships between an individual’s social, cultural, and environmental context, and the health problems they present with.
We do not wander into hospitals when the ships in our lives are sailing smoothly, or even when problems are simmering beneath the surface; we wait, we dilly-dally, and watch what the crowd is up to. It’s probably nothing serious. These give rise to speculations, and as nurse and Médecins Sans Frontières fieldworker Gunnhilder Arnadottir, recounted from her experiences from the outbreak, unfounded beliefs and community fears spanning from “I brought my uncle there and he never came back”, “organ harvesting”, and “they’re using blood for ritualistic ceremonies”. These beliefs may sound absurd, but they are universal, self-perpetuating, and self-destructive, to an incredible degree.
It is only when acutely ill, uncertain, and desperate, that we bolt through those doors – and this delay is one part of the problem. The Ebola virus has escalated to the amplitude that it has because this is, without any doubt, a ‘global health’ dilemma. It is with this perspective, rather than that of a purely biomedical one, that this article reviews and paraphrases the key points of the event. Its content can be accessed at https://www.facebook.com/events/1485070905111886/.
Dr. Cox-Singh: The preventative boat was missed
The Ebola virus was first identified in 1976, and its management has occurred cyclically since then in more or less a similar fashion. ‘Index’ cases – the first affected – were isolated. ‘Outbreaks’ have often been contained via the entry of international, rather than local, teams.
Given the high viral load present within those symptomatic for the illness – and for approximately 21 days afterward – carers are also directly at risk. There is, therefore, an urgent need for snappy identification, to avoid the incidence of remnant outbreaks. That is to say, unsuspecting contacts with body fluids, or of surfaces in contact with body fluids, of affected individuals, multiply into further transmissions. Within close and densely populated communities, this is a real possibility.
“Everything we know about Ebola suggests that it spreads in a limited number of well-defined ways, such as the intensive care of sick patients and the mortuary preparation of those that have succumbed to the disease. With circumscribed capacity to spread along with distinct, identifiable symptoms, this virus doesn’t have pandemic potential.” 
The greater the number of people infected, the more difficult an outbreak is to contain. The first priorities are self-evident, and relegated to the investigative journalist of medicine: the epidemiologist. Who was affected? Who should we tell? And who have they been talking to? The affected cases are, naturally, isolated and treated.
History revealed recurrent outbreaks, but no funding had been unleashed for a vaccination. As retrospect tends to provide an unfair degree of balance and wisdom, it is worth considering that many healthcare systems function on the principles of ‘essential health packages’. Decisions of what conditions to treat are not made by a process of exclusion, but rather one of inclusion. There is a “guaranteed minimum” of treatments provided via a utilitarian approach. A vaccine was perhaps not a top-priority – not for governments, and certainly not for pharmaceutical companies, who operate by the free-market. The New England Journal of Medicine (NEJM) reported, in 2014, the efficacy of a neutralising antibody produced against a glycoprotein spike conserved between species of the Ebola virus, in non-human primates. In the context of an uncontrollable outbreak, funds are now being poured into clinical trials, the search for a preventative has been fast-tracked, and ethics have been reconsidered with regards to experimental therapy – a throwback to the days of the hunt for antiretroviral therapy for HIV, a heroic and flexible push.
The fruit bat appears to be a possible reservoir for the virus; in cultures where such bush-meats constitute a key source of protein, this is possible. Dr Cox-Singh argued that, in her experience, given the low viral titres measured within fruit bats, there are likely to be ‘amplifying hosts’ – monkeys, deers, and macaques, for instance – during the transmission of the virus.
In the African continent, however, severe, acute, haemorrhagic fevers are not uncommon. If an individual presents with fever, diarrhea, and vomiting – how do we know it’s not ‘just’ malaria, for instance? The non-specificity of the symptoms of the Ebola virus make its recognition particularly difficult, and the average period between identifying an index case, and detecting an outbreak, is 3-4 months. This is a notable lag. The ancient, Zaire-type, ebolavirus, made its debut in March 2014, but where was the response?
“Silence, denial, and fear, kill. Instead of permitting hard-working Ministries of Health to identify affected regions and anticipate future spread, they fan the flames.” 
Back to basics
As is the case for most tragedies, a spotlight is shone into crevices and foundational weaknesses. The Ebola virus has been described as a ‘stress test’; a healthcare system already functioning at full capacity – dealing with a population of patients who are weak, undernourished, and co-morbid – is certain to crack under the unique healthcare challenges of dealing with the specific infection control procedures that accompany such a disease. This has been the case for Guinea, Sierra Leone, and Liberia, in Western Africa.
A Polymerase Chain Reaction (PCR) amplifies gene sequences; a PCR designed specifically for a particular virus would amplify its encoded genetic material, indicating to us that it is present. This is a means of rapid diagnosis.
But what can we accomplish with PCR machines if we lack the means of measuring a patient’s electrolyte balance, and the ability to monitor and verify his or her levels of hydration? This is a real problem in the field – published in a Perspective piece in the NEJM – that perfectly encapsulates the concept of ‘inappropriate aid’.
As with any gastrointestinal disease, a clinical syndrome of vomiting and diarrhea is best treated with fluid replacement and supportive care. This is certainly why paranoia experienced in countries of good baseline immunity is utterly unjustified. The risk of mortality is simply not equivalent.
We have discussed vaccines. Vaccines are prophylactic. The damage has already been done. Without basic equipment and amenities, we cannot control and contain an ongoing outbreak. It is with this I attempt to capture the clinical field experiences of Gunnhilder, a nurse who has worked in Sierra Leone and Guinea during this particular outbreak. I was paralysed in my seat, vicariously experiencing on-the-ground scenes through her vivid and impassioned descriptions. She spoke with cynicism, optimism, and practicality, as healthcare workers must often do.
From the field
No one saw the outbreak coming. She signed up early, and they told her she would be recruited if it were still going on in June. The irony was piercing – she ultimately worked in the field for three months.
MSF is acclaimed for its hands-on approach to medical emergencies. No medical personnel can function without the basics: they require logisticians, technicians, and people who can-do, to accommodate their camp sizes and patients, to switch the electricity on, and to keep the water flowing.
At time of the event: October 14th, 2014:
No. of reports: 4,655
Deaths: 2,431 (52% mortality rate)
As of November 9th, 2014 :
No. of reports: > 14,000
Incidence and mortality rates, according to Gunnhilder, were almost certainly being underestimated. She provided the example of 11 infected individuals presenting to their centre, arriving from the same town. This was followed-up by a visit from the epidemiologist, who discovered that 21 people had already died there, without any form of notification.
21 days were counted prior to the decontamination of a camp – essentially before a collective breath of relief could be taken on behalf of all healthcare professionals involved. She described the absurdity of all the professionals on the ward backing away in fear from a toddler who had escaped from isolation, as one scarpered to put on his protective suit. This was a toddler, as it happens, who had just been orphaned.
Existing healthcare infrastructure are at full capacity: no surgeries are being performed, approximately one-third of staff have died during the outbreak, there is a lack of obstetric and emergency care, and perhaps understandably, there is general unwillingness to deal with the outbreak. Essentially, Ebola virus-related deaths have extended beyond the pathological and long-term psychological effects of the virus itself.
She was exhausted – it was a battle. Part of the satisfaction derived from her work was that of seeing improvements, and of seeing patients become clinically well and able to lead happy lives. For this particular outbreak, she was dealing with her own incapacity to treat and manage progress; on returning, she felt intense guilt. It is no surprise that this is a mission for which MSF has stipulated mandatory psychological counseling. For healthcare workers to deal with the problems of others, it is no secret that they must be able to look after their own.
I mentioned a cynicism – she proposed that improvements were unlikely to be experienced in the near-future, a prognosis consistent with the statistics I refer to one month later. I also mentioned an optimism – she recommended the following:
- Post-mortem disinfection and burials must be carried out quickly, as an infected corpse is highly infectious. This is under the remit of the Red Cross;
- Vaccinations are required in Western Africa;
- Having said this, a ‘cure’ is not the primary need, but rather, better management of healthcare infrastructure and healthcare burdens;
- With good immunity, and good infection control, the virus runs its course to leave the patient alive. It is surviving the course of this illness that is problematic;
- Rapid diagnostic tests would be useful in the protection of ill patients who do not carry the viral infection;
- Public health education.
Her heartbreak was plain and bare. She was, as we have established, “a world away”, and discussed her struggles with conveying the importance of working ‘upstream’.
It is difficult to make conclusions in the midst of an ongoing event. The Ebola virus epidemic is not of a proportion that has significantly devastated human populations, and is controllable – but neither of these will be of solace to those directly confronting death row, for those indirectly dealing with its consequences. I will choose to conclude with Buddhist philosophy, “Pain is inevitable; suffering is optional.” – disasters string out a beautiful human resilience, as well as a grief and sadness. The assiduity, the work ethic, and the dedication, demonstrated by those rising to its challenge, are aspirational. Intravenous drips, pipettes, and empathy, are our weapons. And ultimately, when the storm has passed – because it will – what are we going to change to ensure we can cope with whatever viral evolution throws us?
Kick Ebola Out! is a medical student-run campaign by the Sierra Leona and Guinean Medical Students’ Association.
- “Ebola: Mapping the Outbreak.” BBC News. BBC, 11 Dec. 2014. Web. 12 Nov. 2014. <http://www.bbc.co.uk/news/world-africa-28755033>.
- “Essential Health Packages: What Are They For? What Do They Change?” WHO Service Delivery Seminar Series DRAFT Technical Brief (2008): n. pag. WHO. Web. 12 Nov. 2014. <http://www.who.int/healthsystems/topics/delivery/technical_brief_ehp.pdf>.
- Lamontagne, Francois, Christophe Clément, Thomas Fletcher, Shevin Jacob, William Fischer, and Robert Fowler. “Doing Today’s Work Superbly Well – Treating Ebola with Current Tools.” New England Journal of Medicine. New England Journal of Medicine, 23 Oct. 2014. Web. 12 Nov. 2014. <http://www.nejm.org/doi/full/10.1056/NEJMp1411310>.
- Wolfe, Nathan D. “The Truth About Ebola.” Time. Time, 1 Aug. 2014. Web. 12 Nov. 2014. <http://time.com/author/nathan-d-wolfe/>.