The magazine’s science journalist brings dramatic testimony from Liberia and
Sierra Leone, hotbeds of ebola.
At the heart of an epidemic
23/08/2014
‘Only if the world helps us will we be able, in a few months’ time, to get this
horrible disease under control.’
The current ebola epidemic is many times larger than ever before in the number of
victims, the length of the outbreak, and the size of the territory affected. So far in
West Africa, there have been 2,473 cases of ebola resulting in 1,350 deaths, writes
Tanja Rudez.
The current situation in Liberia is truly dramatic because of ebola. All of the
appeals from international organisations such as Doctors Without Borders who
are fighting on the frontlines treating patients in Liberia are more than justified.
Many hospitals are closed because staff are infected with ebola. Some aviation
companies have stopped flying to Liberia and many companies have shut down
their operations there. Food and transport prices are rising so there are fears
there could be unrest in this impoverished country, says Brigadier Predrag
Mikolic, who has been in Liberia as a member of the UN Mission (UNMIL) since
last November. Mikolic’s voice sounds a little tired. From early morning until
evening, this Split resident who was first an army observer in Sierra Leone, then
an officer in Afghanistan, then at NATO in Brussels is now dedicated to only one
goal: to quench what has so far been the biggest and longest epidemic of ebola,
one of the deadliest diseases for which mankind has neither vaccine nor
medicine. It’s not only Brigadier Mikolic: many thousands of UN forces have set
their priorities as stopping the epidemic of ebola in Liberia.
False hope
Heavily devastated by a bloody civil war, Liberia has been fighting a horrible
battle for the past few months with the ebola virus, which has taken away 572
lives already out of 972 people it infected. ‘Ebola started in Liberia in March this
year, after cases in Guinea and Sierra Leone were recorded. And just when it
looked like we had the epidemic under control, because 42 days had passed since
the last case, the disease reappeared,’ Mikolic tells me, and then explains how
ebola started spreading again in May. ‘One woman was at a funeral in a distant
part of the country when she got infected and transmitted the disease to
Montcerrado county which Monrovia belongs to as well. One of the most
frequent ways in which ebola spreads in Liberia is precisely through funerals
because the tradition here is to have physical contact with the deceased,’ Mikolic
explains.
The fact that physical contact with infected people was key to spreading the
disease was highlighted by Dr. Linda Rahal, a doctor from Freetown, capital of
neighbouring Sierra Leone in which 374 have died out of 907 people infected so
far. Linda Rahal was educated in the USA and now works for the World Health
Organisation at the Ministry of Health of Sierra Leone. She spent Wednesday in
areas hit by ebola and spoke to me on Thursday, just before a press conference in
Freetown.
No information
‘We are fighting with all our strength, but the ebola epidemic has a huge
influence on our country’s society and economy,’ says Rahal. ‘The key for
prevention of the ebola epidemic is information. The problem is that our people
don’t understand information about ebola and don’t know how to turn it into
protective measures. Also, in Sierra Leone the culture is predominantly closed,
whereby people often touch themselves to express mutual closeness, and that
only increases the spreading of the disease. That is the reason that ebola has
spread so far,’ explained the African doctor.
Although the impoverished countries of west Africa have been battling this
deadly infectious disease for months, it looks like the developed world only
become aware of ebola after a priest, Miguel Pajeras, died in a Madrid hospital, as
the first European who was infected this year by helping patients with the
disease. Many have faced the fact that in a globalised world, viruses and diseases
are no longer limited to isolated areas of a jungle but instead thanks to intense
airway traffic can travel with people from one part of the world to the other.
Ebola has so far been limited to some isolated areas in Africa. It first appeared at
the end of August 1976 in a Catholic mission in Yambuku, deep in the tropical
forest about 1,000 km north of Kinshasa, the capital of the Democratic Republic
of Congo (then Zaire). The first cases were noted in one village on the banks of
the river Ebola: all of the infected people suddenly got a high temperature,
headache, vomiting, diarrhoea, strong muscle pains, voluminous bleeding and
finally organ failure. The mortality rate was high: of 318 cases, 280 ended fatally.
In a small hospital run by Flemish nuns, 11 of 17 members of the medical staff
died soon after. Risking his own life, a Belgian doctor and scientist, Dr Piter Piot,
bravely headed to Yambuku with his colleagues. Soon they discovered that the
key to the spreading of the infection was badly sterilised needles in the hospital
and close contact of healthy people with the deceased just before the funeral.
Piot and his colleagues set up a quarantine and microbiological analysis showed
that the cause of the deadly infection was a virus. They called it ebola.
‘Intellectually the most exciting and at the same time terrifying aspect was the
fact that we didn’t know at the time how the virus was being transmitted: air,
food, mosquitoes, sexual contact, blood or water, which are the usual ways of
transmitting a virus,’ Piot remembered in a conversation with Jutarnji List two
years ago. ‘So it wasn’t clear how we were supposed to protect ourselves.’
Since that first instance of a new and terrifying disease, there have so far been 20
ebola epidemics. Given that these epidemics broke out in isolated African villages
near tropical forests far from urban centres, the number of victims was mainly in
the range of tens and sometimes hundreds of people. When the world media
reported back in March on the first cases of ebola in Gueckedou prefecture in
southern Guinea, it seemed that this epidemic would be also be limited to a
narrow area. That was wrong: today we know that ebola in Guinea appeared
towards the end of last year and its first victim was a two-year-old boy from the
village of Meliandou in Gueckedou who died on the 6th of December 2013. Soon
after, his mother and three-year-old sister also got the disease and died, and the
villagers that were in contact with them spread the sinister virus to other
villages. By the end of March, the World Health Organisation reported ebola in
four districts of southern Guinea and the first cases in neighbouring Sierra Leone
and Liberia.
‘This epidemic started in southeastern Guinea at the border with Liberia and
Sierra Leone where there are many roads and dense traffic with many people
crossing the borders. The epicentre of the epidemic was near urban centres so
the human-to-human contact was much larger than in previous epidemics which
were recorded in isolated villages whose citizens weren’t overly mobile,’ says
Srdjan Matic, coordinator for environment and health in the regional office of the
World Health Organisation in Europe.
Since May this year, Liberia and Sierra Leone took the unenviable lead in the
number of victims and during the summer the first cases of ebola have been
recorded in Nigeria. ‘So far in west Africa, there have been 2,473 registered cases
of ebola, of which 1,350 resulted in death,’ says Nyka Alexander, who is in charge
of public relations at the WHO’s coordination centre for ebola, which is located in
Conakry.
The death of doctors
The reasons for the seriousness of the current ebola epidemic, which is many
times bigger than all previous ones in terms of the number of victims, length of
the epidemic and the size of the territory it affects, the WHO experts also see in
the fact that the heaviest-hit countries have modest or nonexistent public health
services, so the conditions for an outbreak of any infectious disease is
dramatically bigger than elsewhere. Guinea, Liberia and Sierra Leone are
amongst the poorest countries in the world, and years of bloody conflicts and
civil wars have destroyed their education and health systems. For example, in
Liberia there is only one doctor per 100,000 citizens and in Sierra Leone there
are 2.
‘The worst hit in Sierra Leone are Makena county, towards the border with
Guinea, and the areas bordering Guinea, Sierra Leone and Liberia. This region is
densely populated and very undeveloped, despite it being a hotbed of diamond
mining,’ says Ivica Stankovic, a football manager from Johannesburg who lived in
Sierra Leone from 1997 to 2003 and visited Liberia several times.
‘I worked for a humanitarian organisation, World Vision, and my permanent
base was Freetown, but I was often in districts which are now hit with ebola. I
have many friends there whom I am in contact with and for whom I fear. People
in these countries have it hard anyway, and especially in such an extraordinary
situation because they have neither the human resources nor the infrastructure
to cope with ebola,’ says Stankovic. He also knew Dr. Sheikh Umar Khan, leader
of an expert team for fighting ebola in Sierra Leone, who recently died himself
from this terrifying disease. One of the characteristics of this epidemic is
precisely a very large number of infected and deceased medical workers: so far
160 have been infected and 80 of those died.
Below standards
‘Ebola is new in this part of Africa, so the population and health workers don’t
know the symptoms of the disease or how to prevent them. Many health workers
were scared and didn’t know how to protect themselves from infection. Health
systems in these countries were weak at the start of the epidemic and ebola has
weakened them even further. It was necessary to close several medical centres
to disinfect them properly,’ highlighted a spokesperson for the World Health
Organisation in Conakry, Nyka Alexander.
The fact that hospitals in west Africa have much lower standards than those
we’re used to is testified to by the experience of a doctor from Split, Dr. Marijana
Geets-Kesic, who spent almost two years volunteering in a local clinic in
Freetown in the early 2000s. ‘It’s hard to describe: the clinic was under a roof
made of sheet metal without windows and there were animals walking through
it. The hospital had some beds, but only some patients lay in them. Others lay on
the floor. Most of these people were so poor that they had never slept on a bed
before,’ remembers Marijana Geets-Kesic. ‘Women were giving birth while
chickens walked around them. Malaria and AIDS were a daily occurrence. Every
day I had at least one or two patients infected with HIV. There was no ultrasound
or MRI in the hospital and it was unsafe because of the rebels. Despite all of that,
it was a big challenge for me to help these people,’ added M. Geets-Kesic.
Given that the epidemic hasn’t been brought under control even after 6 months,
the WHO has proclaimed ebola an international threat. They have introduced a
series of measures, amongst which is a recommendation to stop air traffic to and
from affected countries. Neighbouring countries introduced special measures
says Marko Skreb, former governor of the National Bank who now works in
Ghana as an official with the International Monetary Fund. ‘Ghana has introduced
quite a few measures, although it still doesn’t have any cases of ebola. Among
these measures is a ban on any international conferences or gatherings in the
next three months. Several isolation centres have been set up and at the airport
in Accra there are sanitary staff who look over people who come in with
symptoms,’ says Skreb. ‘They’ve especially insured all doctors and medical
nurses and limited travel to the affected countries. In the public institutions,
including my office, there are educational posters about ebola and hand
disinfection units. Also, the media constantly transmit instructions on how to
prevent infection,’ added Skreb.
Plan for ebola
While around the world there have been increased precautions to prevent the
infection spreading, in the affected countries there are superhuman efforts to
control the deadly virus. ‘For us the challenge now is to discover every new
suspected case and all of its contacts and to follow them for 21 days to ensure
medical attention as soon as the person gets sick,’ says Nyka Alexander.
Meanwhile, Croatian Brigadier Predrag Mikolic together with thousands of other
members of the UN who are taking care of peace and safety in Liberia are trying
to help the local population to control the dangerous disease. ‘People in Liberia
are uninformed and uneducated and often follow traditions that only aid the
spread of infection.’ And Dr Linda Rahal and her colleagues are also trying to
educate people so that they don’t hide symptoms of ebola because of a fear of
being stigmatised. ‘Our country has a plan for ebola that were are trying to
implement now. One of the strategies is isolating suspected cases and when they
are confirmed, putting them into medical centres. In Sierra Leone, even some
villages are in quarantine to prevent the spread of the disease and their citizens
are given food and necessary medicines,’ says L. Rahal. ‘But we need help from
the WHO and Doctors Without Borders because we have a problem with human
potential and the capacity of our medical institutions,’ highlighted L. Rahal. ‘The
duration of the epidemic will depend on how people react to information about
ebola and on the amount of help we get in fighting this infection. If we get the
help, and if our people follow the prevention measures, we could end this
epidemic in a few months’ time, that is, by the end of this year,’ concludes Linda
Rahal.
Ten facts to know about ebola
1) What is ebola? It is an infectious tropical disease considered by Doctors
Without Borders to be one of the deadliest diseases in the world.
2) What causes the disease? The cause is the epinomious virus, named after
the river Ebola in the Democratic Republic of Congo where the disease
first appeared in 1976.
3) How is the disease spread? Ebola is not spread by air, but through direct
contact with the bodily fluids of an affected person, such as blood, saliva,
feces and sperm.
4) Who is at greatest risk of infection? The greatest risk of infection is faced
by family members of infected people, those who are in contact with the
bodies of the deceased, and those who take care of infected people
including medical workers who do not wear protective gear.
5) What is the incubation period? From 2 to 21 days. During this period, if
the patient is infected but has no symptoms of the disease, there is no
secretion of the virus and so these patients are not infectious.
6) What are the symptoms of ebola? The early symptoms ressemble flu, and
include weakness, muscle pain, headache, high temperature, and cough.
Some patients get a rash, hiccups, chest pain, heavy breathing and
swallowing, and their eyes become red. As the disease develops, there is
vomiting, diarrhoea, internal and external bleeding, and kidney and liver
failure.
7) What is the source of the ebola virus? The origin of the virus is not fully
understood, but it probably comes from the natural reservoir of fruit bats.
So far, ebola cases have come from contact with blood, organs or other
bodily fluids of infected chimpanzees, gorillas, fruit bats, forest antelopes
and other species.
8) How many types of ebola virus are there? There are five types of the
virus, the deadliest of which is the Zaire strain that first appeared in 1976.
The cause of this epidemic is a strain very similar to the Zaire strain. At
the beginning of this epidemic in March and April, the mortality rate was
very high, but it has now stabilised at 64%.
9) Are there any vaccines or medicines against ebola? So far, there are no
registered vaccines or medicines against ebola, although a certain number
of products is in development.
10) How do you fight ebola? The only available measures that work are
preventative, aiming to stop further transmission of the virus from one
person to another. This includes isolating infected and diseased people,
using protective suits and gear, washing and disinfecting hands, properly
dealing with the deceased, keeping an aseptic environment in the areas
where patients are being treated, etc.
[Pictures of ebola funerals in west Africa, a map of west Africa showing affected
areas]