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By Margaret Chan, M.D.
August 20, 2014
DOI: 10.1056/NEJMp1409859
Many people have asked me why the outbreak of Ebola virus disease in West Africa is so large, so severe, and so difficult to contain. These questions can be answered with a single word: poverty. The hardest-hit countries, Guinea, Liberia, and Sierra Leone, are among the poorest in the world. They have only recently emerged from years of conflict and civil war that have left their health systems largely destroyed or severely disabled and, in some areas, left a generation of children without education. In these countries, only one or two doctors are available for every 100,000 people, and these doctors are heavily concentrated in urban areas. Isolation wards and even hospital capacity for infection control are virtually nonexistent. Contacts of infected persons are being traced but not consistently isolated for monitoring.
Large numbers of people in these countries do not have steady, salaried employment. Their quest to find work contributes to fluid population movements across porous borders. The area where the borders of the three countries intersect is now the designated hot zone, where transmission is intense and people in the three countries continue to reinfect each other. Recent decisions to quarantine this area have brought extreme hardship to more than a million people — but are essential for containment. These are only some of the many challenges to be overcome in the worst Ebola outbreak in the nearly four-decade history of this disease. The needs are enormous; the prospects for rapid containment are slim. The outbreak, in all its unprecedented dimensions, is an emergency of international concern and a medical and public health crisis, but it is also a social problem.
Now, 6 months into the response to the outbreak, fear remains the most difficult barrier to overcome. Fear causes people who have had contact with infected persons to escape from the surveillance system, relatives to hide symptomatic family members or take them to traditional healers, and patients to flee treatment centers. Fear and the hostility that can result from it have threatened the security of national and international response teams. The fact that Ebola is frequently fatal and has no cure further fuels fear and perpetuates these dangerous behaviors, underscoring the importance of having medical anthropologists on the response teams. One urgent priority is to change long-standing funeral practices that involve close contact with highly infectious corpses. In Guinea, for example, 60% of cases have been linked to traditional burials. Rumors, whether about witchcraft or miracle cures, abound; at least two Nigerians have died after drinking salt water, which was rumored to be protective. Good communications and community engagement are urgently needed to combat denial, rumors, and behaviors that fan new transmission chains.
Fear and anxiety have spread well beyond West Africa to engulf the world. Nigeria’s first case of Ebola, confirmed in July in the teeming city of Lagos, was a wake-up call. This was the first time the virus had spread by air travel, and it strongly suggests that any city with an international airport is at risk for an imported case. Even in wealthy countries with well-educated populations, fighting fear with facts is hard. Intense media coverage has allowed the world to see what can happen when a lethal and deeply dreaded virus takes root in a setting of extreme poverty and dysfunctional health systems. The world is seeing the outbreak’s multiple human tragedies: abandoned rural villages and orphaned children, economic and social disruption in capital cities, extreme daily hardship in the quarantine zones, riots, uncollected bodies, and above all, the unprecedented number of medical staff who risked their lives and lost them. To date, nearly 160 health care workers have been infected, and more than 80 have died.
The loss of so many medical staff impedes outbreak control in significant ways. It depletes one of the most important assets for controlling any outbreak. It can lead to the closing of hospitals, especially when staff refuse to come to work, fearing for their lives. It increases the level of anxiety: if trained and protected medical staff are getting infected, what hope is there for the general public? And it has made it difficult for the World Health Organization (WHO) to secure support from sufficient numbers of foreign medical staff. I have spoken with the presidents of Guinea, Liberia, and Sierra Leone on several occasions. They are frank in their assessment: the outbreak far outstrips their capacity to respond. The attitude of the public is summarized in two sad words: helpless and hopeless. Their most urgent request is for more medical staff. Staff needs are high. Personal protective equipment is essential, but it is hot and cumbersome and therefore severely limits the time that doctors and nurses can spend working on an isolation ward. According to current estimates, a facility treating 70 patients needs at least 250 health care workers.
The situation continues to deteriorate in the hardest-hit countries, but the response has improved over the past 2 weeks. More aid, from individual countries and the World Bank, is coming in. The World Food Program, with its unparalleled logistic capabilities, is addressing daily material needs in the quarantine zones. The WHO is mapping the outbreak to pinpoint areas of transmission and the location of facilities and supplies to ensure that assistance is coordinated and rapidly and rationally distributed. Personal protective equipment is being dispatched on a nearly daily basis. The Centers for Disease Control and Prevention (CDC) is providing robust on-the-ground support, including contact tracing in Lagos. The CDC is also equipping the hardest-hit countries with computer hardware and software that will soon allow real-time reporting of cases. The framework for a scaled-up response, including the deployment of more medical staff, logisticians, and event managers, is rapidly taking shape.
Experience tells us that Ebola outbreaks can be contained, even without a vaccine or cure. Nonetheless, with the formidable combination of poverty, dysfunctional health systems, and fear at work, no one is talking about an early end to the outbreak. The international community will need to gear up for many more months of massive, coordinated, and targeted assistance. A humane world cannot let the people of West Africa suffer on such an extraordinary scale.
Dr. Chan is the director-general of the World Health Organization, Geneva.
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