How to spend $490m in six months

It’s reassuring to know that someone has a plan.  A few days ago the WHO released their Ebola Response Roadmap with the goal of stopping Ebola transmission within 6-9 months in affected countries, and preventing international spread.  It’s sobering to see what financial resources, human and organisational capacity is going to be needed, but more so to observe the assumption that the outbreak is going to get quite a lot worse before it gets better, and that already in some areas the number of cases may be 2-4 times the number we know about.

Let’s take a look inside …

Objective 1: “To achieve full geographic coverage with complementary Ebola response activities in countries with widespread and intense transmission.”

Key Milestones: “Reverse the trend in new cases and infected areas within 3 months, stop transmission in capital cities and major ports, and stop all residual transmission within 6-9 months.”

Focusing on Liberia, Sierra Leone and Guinea, this means caring for Ebola patients in purpose-built treatment centres with full infection control measures, laboratory diagnosis facilities, contact tracing and monitoring, supervised burials, and engagement with communities.  Areas with intense transmission will be continuously identified and monitored, and the interventions will be significantly stepped up in these locations.  To limit national spread, where there are ‘containment areas’ (quarantined communities) this means ensuring that basic services such as primary health care, psycho-social support and food are provided.  Public gatherings should also be deferred.  To limit international spread, there will be exit screening at all major land, air or sea borders and no Ebola sufferers will be allowed to travel unless by medical evacuation.  There will also be an effort to cover the gaps in essential services such as health care, education, water and sanitation, food, and protection.  An investment plan to strengthen health services in the longer term will be developed, as well as a fast-track training programme for health workers.

Objective 2: “To ensure emergency and immediate application of comprehensive Ebola response interventions in countries with an initial case(s) or with localised transmission.”

Key Milestone: “Stop all transmission within 8 weeks of index case.”

In countries like Nigeria, and now Senegal, where there has been a first case (known as an ‘index case’) and perhaps some transmission on a relatively small scale, emergency health procedures should be instigated, including the establishment of an emergency operations centre and plans for coordination and communication.  Ebola response protocols must be followed, including isolating patients in a designated treatment centre, accessing diagnostic capacity, contact tracing/monitoring, safe burials and good public communication.  Again, international spread must be prevented by forbidding travel by Ebola-sufferers.

Objective 3: “To strengthen preparedness of all countries to rapidly detect and respond to an Ebola exposure, especially those sharing land borders with an intense transmission area and those with international transportation hubs.”

Key Milestone: “Full Ebola surveillance preparedness and response plan established in areas sharing a land border with an Ebola-infected country and at all major international transportation hubs within one month.”

Neighbouring countries are most at risk of international spread because of porous land borders (that’s how Ebola got to Senegal), and transport hubs (as we have seen in Nigeria) are also vulnerable.  All countries should be prepared – by providing travellers to affected areas with information, ensuring an isolation facility is available along with arrangements for diagnosis and contact tracing, if needed.  Countries with a land border should also provide the population with accurate information about Ebola and how to prevent it, begin active surveillance for any clusters of unexplained deaths (particularly near borders) and put in place means of managing travellers at major land crossings who show signs of fever.  International travel hubs also need to be prepared to manage passengers with unexplained fever.

None of this comes cheap – a budget of $490 million (£295.3m) is projected for a six month period.  Hard to fathom, isn't it?  Money isn't everything though – the plan also identifies the need for 3170 national staff, all in skilled or semi-skilled roles, and 410 international staff, in Liberia alone.  Finding those people will not be straightforward.  I can’t help thinking had this level of coordination been put in place earlier, things might never have got this bad.

Then there are the things that the budget doesn't include – such as the costs of supporting essential services to be provided in the worst-affected countries, and the costs of health systems recovery and strengthening in these areas.  Who, I wonder, is going to take care of that?

For the keenies, the full Roadmap can be found here: http://apps.who.int/iris/bitstream/10665/131596/1/EbolaResponseRoadmap.pdf?ua=1

The anxiety of the uninfected

About a week after I returned from Liberia I got a cold. It started with a headache - a classic early Ebola symptom. Being perhaps a little run down after an intense period of work and travel, it hit me hard, and I felt exhausted and weak. The thought crept into the corner of my mind, what if I have Ebola?

Being a rational sort of gal I knew this was intensely unlikely. I was in a 'low risk' category. High risk people are the family of Ebola sufferers, medical workers and aid workers in affected communities or treatment centres. As a foreign visitor who had never knowingly come into contact with a sick person, I could only have contracted Ebola by touching someone or something contaminated with an Ebola patient's bodily fluids, then eating, rubbing my eyes or nose or touching a broken area of skin before washing my hands. I didn't honestly believe this had happened.

But it was just possible ... so how far should I go in taking precautions? Should I sleep in the spare room and keep my husband away? Should I refuse entry to my home when my friend visits with her 11 month old baby? Should I try not to touch my young niece and nephew? It's easy to be logical when it is only your own health at stake, but the thought of putting loved ones at risk bred a gnawing anxiety.

I'm just one person with access to good information sources - so I carried on as normal and checked my temperature regularly for my own peace of mind. But what happens when you multiply that nagging doubt, that hypothetical guilt, to a whole population? Only a minority may be acutely affected by Ebola, but no one is untouched - the whole of West Africa is on edge.

Treatment

The human body is an amazing thing.  We’ve studied it for centuries, and still there is so much that we don’t understand.  Its ability to heal and regenerate itself must be one of the most intriguing things about it - in film and television this is often exaggerated and described as a superpower (X-Men, Heroes …) but the truth is we are all capable of self-regeneration – just not instantaneously!  Something that I didn’t know before my husband specialised in intensive care medicine is how much our most high-tech medical interventions rely on the body’s own ability to heal itself.  Notwithstanding antibiotics to kill bacteria and so on, fundamentally what intensive care offers is the skills, drugs and technology to support failing systems in the body, keeping it going and buying it time to repair itself, or not.

No matter where you are in the world, in the absence of any cure, the treatment for Ebola is supportive care.  Its purpose is to keep the patient alive as long as possible to give the immune system the time it needs to mobilise its response, which will be new and specific to the virus that it is up against.  That is why there has been some benefit in previous outbreaks in using serums to treat Ebola – that is, extracts from the blood of Ebola survivors that can be injected into Ebola sufferers.  Their blood contains the antibodies that the immune system has generated, which gives the recipient’s immune system a head start in working out what to do about the viral invasion.  The body is capable of eliminating Ebola – we just don’t know how.

In Ebola treatment centres in West Africa run by MSF or in hospitals, this supportive therapy focuses on the basics of life.  They are kept hydrated, and their oxygen status is maintained.  This keeps their blood pressure as stable as possible.  Since their immune system is otherwise occupied they are susceptible to other infections, and these can be treated.  Beyond that, all we can do it watch, and wait – but the time that this supportive treatment buys a patient can make the difference between life and death.  MSF estimates that early treatment can improve the chances of surviving Ebola by 10-15%.

Of course, what would really buy Ebola patients time is access to the full works of intensive care support – invasive ventilation, powerful drugs (inotropes) that modulate blood pressure and heart contraction, haemofiltration (like dialysis) to replace non-functioning kidneys, one-to-one nursing … Not only would this give the immune system time to work its magic, but even for those who did not recover, their death would be far less traumatic.  As soon as it became clear that the patient was deteriorating into severe multi organ failure, they would be anaesthetised and ventilated, so as well as receiving other treatments to give them a chance, they would not suffer.  The trouble is, this comes at a cost.  In the UK, a bed on intensive care costs on average around £2000 per night – so that would be £28,000 for just one patient with two weeks of Ebola.  It also requires a consistent and safe supply of a wide range of drugs, lots of nurses, complex equipment that requires a specific skill-set to operate, even amongst doctors, a lot of clean water and a reliable electricity supply – you can’t very well provide life support where there is a risk of a power cut.  Too bad it’s not countries that can afford it that get Ebola.

'Fear will be your enemy'

Everyone who is parent to or otherwise spends time with a girl under the age of, say, 13, will know that when fear grips you, bad things can happen.  Especially if you are an ice-wielding princess struggling to control her powers (even if you don’t have any children as an excuse, I still recommend the film ‘Frozen’ as a heart-warming if cheesy use of 108 minutes).  In Liberia, the main reason the Ebola outbreak is not under control is the potent combination of fear, denial and distrust.  We often think of fear as irrational, something that causes senseless action.  It might be tempting to read events like families hiding cases of Ebola in their homes, patients running away from treatment centres, or communities rioting to escape a quarantined area, in this way.  But I think that if we can put ourselves into the position of a person behaving in this way, we can begin to see the logic, consistency and good sense in their actions – and the challenge to change perceptions that the Red Cross and others playing their part in the outbreak response face.

Of course, we’re all a little bit scared of Ebola – it’s a terrifying disease.  Even when we read news articles (or even blogs) about places over three thousand miles away, it still causes us a little anxiety knowing that there are diseases like that out there.  But Liberians have other reasons to be afraid.

Many people in Liberia have had very little contact with Western-style medicine.  Access to health care is very poor in Liberia, and during the civil wars it was virtually non-existent.  Alongside this, there is very poor access to education, particularly in rural areas, for the poorest people in the population and for women, so there has been little opportunity to learn of the benefits of modern medicine.  Rather, people have always relied on traditional healing, including both the use of herbs and roots, and magical interventions, in order to address their ailments.  Many people have rarely or never faced a situation where they have had to trust Western medicine.  Then a relative falls sick with a fever that looks just like the malarial fever that everyone has had at some point in their life.  They are taken away by strangers in strange suits to a medical facility.  Then, their condition worsens, and they die a terrible death like nothing anyone has seen before.  From that perspective, you might be forgiven for thinking, at best, that Western medicine is ineffective, or at worst, that someone has maliciously tortured and killed your loved-one, either directly or through some malevolent magic.  In order to trust someone or something, you need to believe that it is competent to do what is needed, and that it is benevolent to do it.

Then there are the measures that the government is taking to contain the outbreak: road blocks, quarantining communities, soldiers going house-to house to find families who are hiding cases of Ebola in their homes.  This would be intimidating for anyone, but Liberia is a post-war country where most of the population has experienced these things before.  Now I'm not saying these measures are wrong - you would have to ask a Liberian living in the country to make that kind of assessment, I'm in no position to judge the pros and cons of the government's actions.  A Ugandan friend tells me that a tough approach from their government has previously prevented Ebola outbreaks from spreading in his country.  Still, imagine what it is like to have a soldier force his way into your house when the last time this happened, people were screaming, gunshots were being fired, there were bodies in the street and children running into the bush to hide. Houses looted, young boys kidnapped, women assaulted and many people arbitrarily executed. There is a real danger of retraumatising a population with a lot of bad memories.

Survival is a daily challenge for the majority of Liberians, over 60% of whom live below the national poverty line.  Recently, the prices of staple goods such as rice and drinkable water have rocketed by 80%.  The main commercial hub of Monrovia is the Waterside area,  and 70% of traders who serve this economic centre live in the quarantined community of West point,  which had been barricaded for at least three weeks to contain instances of Ebola in this one of the poorest and most densely populated areas in the country.  Add to that the restrictions in cross - border and cross - country trade, and the supply of rice and water, the essentials of life, is in serious jeopardy.  People who already live on the edge of survival cannot afford these price increases - as a Liberian aid worker pleaded on CBC news,

"We need food, we need water. We're not just fighting Ebola here, we are fighting hunger too."

Trust is something that we badly need in order to cooperate with other people without unbearable anxiety.  In order to trust, whether that is medical workers, the government, NGOs, traders of basic commodities or other citizens, people come from a place of vulnerability and uncertainty about how they will be treated. Drawing on past experiences, cultural background and the advice of influential others they assess whether they expect a favourable outcome to arise through trusting. In order to trust, they must make a leap of faith, accepting their vulnerability and acting as if the outcome will be good even though they don't know whether this will be the case. Trust could not be more relevant and essential to Liberia, and it is in the balance in this crisis. A lot hinges on the successful management of the outbreak.

Beauty and the beast

It was with slight guilt that when I first saw a picture of the Ebola virus under a microscope that I thought, “It’s quite pretty!”  The viruses Ebola and Marburg together make up the family Filoviridae, taken from the Latin "filum", meaning thread-like, based on their string-like structure.  The colourful illumination they use to display it makes the virus appear deceptively attractive – the reality is quite the opposite.  It is not just the high death rate that makes people afraid of Ebola – it’s what it does to you in the mean time.

Ebola Virus Disease used to be known as Ebola Haemorrhagic Fever.  Haemor-what, I ask?  This basically means it is one of a group of diseases characterised by fever accompanied by haemorrhage – that is, escape of blood from spontaneously ruptured blood vessels.  Lassa Fever and Yellow Fever also fall into this category, and are among the range of infectious diseases that Ebola may be easily mistaken for.  Here’s how it goes.

The first stage seems mundane – sufferers experience flu-like symptoms such as a sudden fever, profound weakness, muscle pain, headaches and a sore throat.

After 4-7 days, the symptoms develop, and a patient may experience vomiting, diarrhoea, low blood pressure and anaemia.  You can’t see it yet, but these are clues that the bleeding has started.

Not everyone will make it as far as the final, most gruesome stage.  Some recover, some die before the bleeding becomes evident beyond some bruising or bleeding from the gums.  After 7-10 days, Ebola has been causing blood vessels to rupture and has prevented coagulation (clotting), so that there is internal and external bleeding.  People bleed from the eyes, ears and nose.  They may vomit, cough up or excrete blood.  Bleeding under the skin causes a rash all over the body (similar to the non-blanching rash shown in severe meningitis).  The kidneys are often the first to give up.  In the end, at this stage, the bleeding and infection cause low blood pressure leading to multi-organ failure.  That is what will bring their suffering to an end.

For better or worse, the disease usually takes about two weeks to run its course.  Not so pretty now.

A dubious discovery

Many a young inventor or scientist yearns to make an historic discovery, one that will change the world.  But I wonder what it feels like when that discovery is a problem, rather than a solution.  Of course, one is required in order to reach the other, but it’s a funny sort of hero who makes his name for discovering the Ebola virus.

In September 1976, a blue thermos flask arrived at the Institute for Tropical Medicine in Antwerp, Belgium.  Inside, packed in half-melted ice, were vials of blood taken from a Belgian nun working in Zaire (now the Democratic Republic of Congo), who was suffering from an illness that no one could identify.  This was the first time Ebola was put under a microscope, by 27 year old trainee microbiologist Peter Piot.  The only known virus that shared its peculiar structure was Marburg, but he soon confirmed that this was something different.  Two weeks later, Piot was part of a team flying to the remote origins of the virus, near the source of the Congo River, in a village called Yambuku.

The answers came through detective work – talking to people and putting the pieces together.  The team noticed that many of those who were suffering from the disease were young pregnant women who had attended antenatal clinics at the hospital.  Resources were scarce, and the women received injections from one of five needles that were used each day.  They also noticed that people seemed to become sick after attending funerals.  Gradually the routes of transmission became clear, and the knowledge that was needed to contain the outbreak could be put to use.  Piot and his colleague took home blood samples that would enable them to identify the virus that they named Ebola, after a near-by river.

Peter Piot has famously stated recently that he would not be concerned to sit next to an Ebola-sufferer on a train, and advised that there will not be a major outbreak outside of West Africa due to the close contact that is required for the virus to spread.  Speaking to a BBC reporter, he stated:

"We shouldn't forget that this is a disease of poverty, of dysfunctional health systems - and of distrust."

If you would like to find out more about Peter Piot’s discovery of Ebola, I thoroughly recommend this article from the BBC’s News Magazine http://www.bbc.co.uk/news/magazine-28262541 and perhaps, like me, you will even be eager enough to get on Amazon and order his memoir ‘No Time to Lose: A life in pursuit of deadly viruses’.  It gives me hope to see what a difference the potent combination of research and lobbying can make.

Burial

The way that we say goodbye to a loved one matters to us.  It gives us a chance to grieve, and to have that grief acknowledged.  It brings closure to the circumstances, whether sudden and shocking or a gradual diminishment, that led to their death.  Whether we had the opportunity to in life or not, it is a chance to say goodbye.  And it provides space to remember the person, to see the person through the eyes of others who loved or respected them, and to together establish how they will be remembered over time.  If we can do this in the way that we feel is right, that reflects well on the person we have lost, the sense of comfort and release can powerfully assist us to let them go.

People are talking a lot about the problems caused by ‘traditional burial practices’ when it comes to Ebola.  This sounds vague and mysterious – partly because practices vary between religious and ethnic groups, according to status and between localities, so it’s hard to pin down exactly what these 'practices' are.  This should hardly be surprising – in the UK, what does a state funeral have in common with a wake in a local pub?  There are subtle and obvious differences between the way that Christians, Muslims, Hindus, atheists and Humanists choose to carry out the process of saying goodbye and remembering.  But what applies across the board is that being denied the chance to do this deprives us of comfort and can leave a sense of having misrepresented the person who died.  The sorrow and anxiety that results from this can be lasting.

When it comes to the burial of Ebola sufferers in Liberia, families may be denied the opportunity to perform the final services of preparation of the body and burial themselves, instead entrusting this important duty to strangers.  They may be forced to breach the wishes of their loved one with regards to how and where they would like to be buried, which would usually be held in high esteem.  They may not be able to mourn as is customary around the body, expressing their grief with the community as their witness.  Most people would wash the body and dress it in a particular way before it is buried.  Instead it must be doused in disinfectant and contained in two bags to ensure that any surviving Ebola virus is killed or contained.  For infection control purposes, it may not be possible for the person’s body to be returned to their village of origin and buried in the right place, whether that is near the family home or in a designated area outside the village.  Where it is possible, people may be too afraid to have the body returned to them.  It is easy to see how difficult this may be for bereaved families to come to terms with, and why some people may resist complying with burial procedures that are necessary to contain the spread of the disease.

I have been to many funerals, but I have never in my life seen a dead body.  From my cultural background, the way that a dead body is handled should be respectful towards the person that was, but is mainly a matter of hygiene and practicality – the person I knew is not there any more.  The circumstances of the funeral are mainly for the benefit of those that are left behind - even for those of us who believe there is life beyond death, this spiritual dimension is somewhere quite removed from the life that the rest of us will keep on living.  That is not how it is for those who hold traditional beliefs in Liberia.  The spiritual realm coexists with the material realm of the living in daily life, and death means a transition between these two realms.  A burial and funeral is a rite of passage that is crucial to making a proper transition between these realms – failure to achieve this may have drastic spiritual consequences.  This is not just sentimentality – the spiritual discord that can result from failure to conduct a proper burial can affect the whole community, and for those that are left can be the greatest source of trauma associated with loss.

Turning it around

The bigger the ship, the longer it takes to turn around.  Being a Southamptoner, I can’t resist a nautical metaphor!  But the same goes for a major outbreak like the one being faced in West Africa.  Experts are now suggesting it will take six to nine months before this is all over.  When the spread of disease is out of control it is hard to imagine how this will end, but it can end, and it will, and the key is public health interventions.  That is where the Red Cross comes into its own.

From the start the Liberian Red Cross has been a core member of the National Task Force in Liberia, which is headed by the Ministry of Health and Social Welfare, and is responsible for coordinating the response.  The Red Cross has been commissioned with responsibility for taking the lead with awareness and social mobilisation activities at county level, due to its unrivaled networks throughout the country.  By the beginning of August, they had already mobilised 650 volunteers, and has been working in a number of areas:

·       Social mobilisation – this is all about reaching people with accurate information about Ebola, helping them to know what steps they can take to protect their families, combating the serious threats posed by denial, fear and panic.  The Red Cross is incredibly well-respected in Liberia, and even by mid-July was reporting having held 93 community sessions, reaching over 32,000 people from 5890 households.

Psychosocial support – counsellors with experience of conflict-resolution and trauma have been coordinated at county-level branches to provide training and support to volunteers out in the community, as they help to minimize fear, stigma and mitigate potential conflict within the affected communities.

Dead body management – the Red Cross is hands-on with assisting to perform safe burials in affected areas, preventing further infection.  By the beginning of August they had already assisted with 70 burials in the capital city state of Montserrado.

Contact tracing – people who have had contact with an Ebola sufferer in the community need to be identified in order to prevent further spread of the disease.  These people are then assisted to monitor their health (particularly through taking their temperature for the duration of the incubation period – 21 days, as we all well know), and they are also provided with education about the disease and support as they go through the anxiety of waiting to see whether they have been affected, as around 1/10 contacts will be.  Over 100 volunteers were trained in contact tracing in three counties by the beginning of August.

In Liberia, the Ebola situation has become a very political issue, and due to lack of understanding some communities have been very resistant to interventions.  This has caused great difficulty in identifying and following up some contacts, and even violent attacks against health workers in some areas.  Still, the Red Cross volunteers and staff are well trained and equipped to carry out their roles safely.  Crucially, they come from the communities in which they are working, which makes a big difference when it comes to disseminating prevention messages or when rumours and cultural beliefs need to be addressed.

There remains an urgent need to improve and scale up contact tracing and dead body management efforts if the spread of Ebola is to be brought under control.  This requires resources – both people and equipment.  Without this either people may be put at risk because of inadequate protective equipment, or people may be forced to work long hours, leading to exhaustion of staff and volunteers working under harrowing circumstances.  The Red Cross has the infrastructure – it also needs the funds.

If you feel inspired to support the Red Cross to fight the Ebola outbreak, click here to go to my online fundraising page where you can donate online easily and securely to support the Ebola outbreak appeal across West Africa.

Tracking the spread

It’s day 11, and this post marks the half-way point through my 21 days of blogging about Ebola, so I decided it’s time for a review of the situation in countries that are affected – and at the same time to clarify definitions that are used to talk about cases.

The figures that we hear reported about the number of cases of Ebola include suspected, probable and confirmed cases.  But what is the difference between these?  Well, following the WHO’s guidelines, a suspected case could be any one of the four following scenarios:

(1) Someone who suffers from a sudden high fever and has had contact with a suspected, probable or confirmed case of Ebola, or with a dead or sick animal.

(2) Someone with sudden onset of high fever who has at least three of Ebola’s symptoms:

• Headaches
• Vomiting
• Loss of appetite
• Diarrhoea
• Lethargy
• Stomach pain
• Aching muscles or joints
• Difficulty swallowing
• Breathing difficulties
• Hiccups

(3) Someone with inexplicable bleeding.

(4) Someone who dies suddenly and inexplicably.

A probable case is a suspected case that has been evaluated by a clinician, OR who has died and had contact with a confirmed Ebola sufferer.

A confirmed case means that laboratory tests have confirmed that the disease really is Ebola.

The thing is, Ebola in its early stages looks a lot like other common diseases in sub-Saharan Africa – particularly Malaria and Typhoid - and there is not always a clinician or a laboratory to hand to examine the case.  When you look at data about Ebola it’s important to understand that it includes these three categories of cases, as otherwise it seems peculiar that sometimes the number of cases seems to go down ever so slightly, rather than up.  The reason for this is that, following laboratory testing, occasionally cases are reclassified.

The graph below tracks the number of (suspected, probable and confirmed) cases of Ebola between 10^th June and the WHO’s most recent report, released yesterday, which includes figures up to 20^th August.

The outbreak began in Guinea, and although the number of cases appears to be climbing in all countries, the rate of transmission is highest in Sierra Leone and Liberia.  If you look just at the two week period up to 20^th August, during this time the number of cases in Nigeria rose from 13 to 16 – that is an increase of 23%.  The number of cases in Guinea also increased by 23%, from 495 to 607 cases.  The number of cases in Sierra Leone jumped from 717 to 910, an increase of 27%.  In Liberia, where transmission is most out of control, the number of cases rocketed from 554 to 1082 – that is an increase of 95% in a fortnight.

Perhaps that is why the President of Médecins Sans Frontières (MSF) commented in a statement just over a week ago that the regional international effort needs to pay particular attention to Liberia if we are to stop the spread of Ebola.

Supply and demand

There was a great debate on Ebola this week hosted by the Thompson Reuters Foundation (http://www.trust.org/spotlight/ebola-when-will-it-end/) which brought together experts who are part of the response across West Africa.  One of the major areas of discussion was, despite funds that are being made available, why are resources lacking to enable an effective response to the Ebola outbreak?  The main things that were named as missing were cars, personal protective equipment (PPE) and skilled workers – in particular, doctors, nurses and infection control personnel.

The lack of cars on the ground did not come as a surprise.  When I was in Monrovia I was astounded to find that even a small, second-hand vehicle that would never pass an MOT in the UK costs around £2500-5000 (that is $4000-8000).  I genuinely looked into whether it would be cheaper to have my £500 faithful old banger shipped to Liberia than to buy or rent a vehicle in order to conduct my fieldwork there.  Even the Red Cross, reliant on having heavy-duty vehicles to reach its offices all over the country struggles with insufficient transportation.  Now that the Ebola outbreak has spread so widely in the country, the need to get people around, particularly in the rainy season, is an enormous challenge.

I find it hard to understand and accept the lack of sufficient personal protective equipment (PPE).  After all, what is it but boots, gloves, boiler suits, masks and aprons?  These all seem to be things that should be common place.  I can only assume that the economic principle of supply and demand applies – there is not usually the level of demand for these items (which need to comply with specific standards to be used for Ebola), so manufacturers are not prepared for a sudden increase in orders.  Or procurers do not know where to source the quantities that are now needed.  Still, this surely is an issue that international organisations should be able to resolve – and they had better do it quickly, as it is closely connected to the question of personnel.

In relation to the staffing needs, Jorge Castilla of the European Commission for Humanitarian Aid (ECHO), based in Guinea, lamented during the debate,

“The gap between needs and offer is big.”

One contributor suggested that potential volunteers from the US might be put off as insurance companies refuse to provide medical protection for Ebola.  I can well believe that – I was recently refused mortgage protection insurance myself because I said I was planning to travel to Liberia.  Perhaps there are also issues of the speed of recruitment processes and capacity to advertise for positions, or the specific profile of volunteer that is needed, particularly those with experience in managing infectious diseases.  But I wonder if the most overriding factor is fear.  Ebola is a terrible disease, and both local experts and international health workers have been infected.  And as we know, there is no ZMAPP left for next time just yet … we also know in theory that Ebola can be controlled when proper procedures are followed, but this is hard to reconcile with the knowledge that people you would not expect to take any risks or deviate from procedures have nevertheless contracted the disease.  I wrestle with this, being married after all to an intensive care doctor.  His work commitments would not enable him to go at present, so it’s a futile dilemma in any case.  But if they did, and if he wanted to, would I entertain the risk of him going?

The potential for impact if foreign medical staff make themselves available is hard to overstate.  The right infection control procedures can enable staff to do their jobs safely.  And in addition to the direct clinical benefits of having the personnel that are needed on the ground, as Jorge Castilla observed,

“Foreign medical staff can create confidence in national staff and show that it is possible to deliver services with no risk because there are adequate measures in place.”

Why I love the Red Cross

I am very proud to be associated with the Red Cross and Red Crescent Movement in my research, as well as in this campaign.  Not only because they have proved to be excellent partners in my work so far in Liberia - there are a lot of features of the organisation itself that I am impressed with.  Another day I will focus on how they are involved in fighting Ebola more specifically – today let me tell you a bit about what I think the organisation has going for it.

1.       The Liberian National Red Cross Society is a Liberian charity.  It was first set up in the aftermath of World War I as a voluntary relief committee.  It serves the Liberian people.  Its staff are Liberian and its National Executive Board members are Liberian.  It is recognised by an act of Liberian law.  The same goes for the British Red Cross, the Sierra Leone Red Cross Society, and every other Red Cross or Red Crescent Society.  They belong to the people who they serve.

2.       It is part of the International Federation of Red Cross and Red Crescent Societies (IFRC).  Each national Red Cross or Red Crescent society does not stand alone, they are members of the IFRC and so are all connected.  This means that knowledge, experience, personnel and funds can move between national Societies, making sure that resources can be applied where they are most needed.  The movement as a whole is more than the sum of its parts.

3.       It unifies people.  The mission statement of the Liberian Red Cross states that it exists “to respond to the needs of the vulnerable people at all times, and to treat them with dignity and without discrimination.”  Sadly, historically, communities in Liberia have been anything but equal, from the disparities between Americo-Liberian settlers and indigenous peoples in the first century or more of the country’s recognition in the Western world, to the different cultural identities that were manipulated and polarised by the instigators of the civil wars.  In its response to human hardship and vulnerability, the Red Cross sets an example of overriding distinctions between people for humanitarian good.

4.       It works in support of the Government.  Many Non-Governmental Organisations (NGOs) across the world do excellent work supplementing Governmental work and filling the breach where Governments lack capacity – this is particularly crucial in the aftermath of wars (civil or otherwise) or natural disasters.  This is life-saving work, and in many cases is done respectfully to and in partnership with the Governments of aid-receiving countries.  However, there can be a danger that as tasks are ‘outsourced’ from any given Government, the country’s political class becomes detached from decision-making in their own field in a way that can be disempowering as donors’ and other interests compete with their authority to govern.  The civil service can be denied the opportunity to develop in its capacity to run its own public services in the future as they are shipped in from outside, fostering a neo-colonial culture of aid-dependency.  The Liberian Red Cross is set up as an auxiliary to the Government of Liberia, and as such serves the Government’s agenda and augments its service-provision capacity.  No wonder it is one of the organisations at the heart of the Ministry of Health’s response to the Ebola crisis.

5.       Its life-blood is local volunteers.  As of 7^th August, the Liberian Red Cross had mobilised 650 volunteers across the country in support of the fight against Ebola – all Liberian.  That is a colossal resource, and in a context where trust is low, the value of public health messages being brought from within communities themselves by their own members cannot be underestimated.

That’s why I love the Red Cross and why I am working to raise support for it at this time of crisis.  If you would like to help with this, click on the image of the motorbike to the right of this page to link to my campaign’s giving webpage.  Thank you for your support!

Hands off

Last month I was visiting a potential field site for my PhD research in Monrovia, and meeting some of the people in the area.  One of the Liberian Red Cross staff was showing me around, and he explained to people that I am a researcher from the University of Southampton, and that I will be coming to do some research in their neighbourhood.  People seemed genuinely pleased, and reassured me, “You are welcome.”  I smiled and shook their hands warmly – we shared a limited amount of language, but at least we could share that basic courtesy, a sign of friendship and respect.  In the UK we shake hands as a formality in quite specific circumstances.  In Liberia, as in many parts of Africa, it is more than that – it acknowledges a person’s value, it says, “I see you.”  After a while, my colleague quietly cautioned me, “Not too much handshaking – Ebola.” 

Of course he was right – physical contact is the way that Ebola is spread.  I don’t know if someone I meet is caring for someone who is sick at home and if we’re all going around shaking each other’s hands by the end of the day, how many people might we have infected?  Sure, it’s unlikely, but it’s not impossible, and if everyone avoids physical contact with others it will have an impact on the spread of the disease overall.  It is sensible and right to avoid too much handshaking.  But what does that mean in a culture where people value physical touch?  When I meet a person I am anxious – if I do not go for a handshake, will they think, “This person is being careful for my health,” or will they think, “This person thinks they are better than me”?  Whatever I do, I risk seeming disrespectful.  In a small, everyday way, no handshaking breaks a simple way that people treat others with dignity.

How much more acute is the rejection when a person is suffering from Ebola-like symptoms, and they are denied physical touch?  Of course this precaution is absolutely essential.  But it is also tragic.  We all know how much we need the reassurance of a kind touch when we are feeling unwell.  Something that says, I see your suffering and I am sorry for it.  Something that says, I care for you.  Something that says, you are not alone – I am here with you.  Instead, suspected Ebola-sufferers must be isolated, and are met with physical barriers that protect their love ones and other carers, but which drive home the message, you are on your own.

I wonder, if I was that sick, whether I would have the strength and grace to see those barriers to touch not as a denial of the love and care that I would crave, but as a way of me asserting my own care and respect for those around me.  Is it possible, in day-to-day life, for people to reverse every instinct and see refraining from touch as an acknowledgement of another person’s dignity, to read the message in hands withheld, “I see you”?

If you would like to support the Red Cross' work fighting the spread of Ebola in West Africa, click on the image of a motorbike on the right-hand side of this page to go to my giving page.

Where has all the ZMapp gone?

After two American aid workers, one Spanish priest, one Nigerian and two Liberian doctors have been treated with ZMapp, there has so far been just one death – 1/6 is good odds in this Ebola outbreak.  So why can’t more people be treated with this promising drug?  Well … because there is none.  And there won’t be any more for a few months.  This is not a limitation that is exclusive to ZMapp – we can expect other drugs to be limited in their availability to meet demand.  So why is that?

Sad but true, the bottom line is cost.  It takes a lot of money to go through the process to develop and test new drugs, and someone has to pay for that.  The immense costs associated with developing and trialling drugs either comes through grants or is met by pharmaceutical companies who will make a long-term profit gain if the drug is successful.  In order to make a business case for this process, either grant-funders or commercial organisations need to see a return on investment.  But previous outbreaks have been small and contained – there simply have not been that many Ebola cases in the past, certainly not enough to justify more than a modest investment, horrible though the consequences are for those that are infected.  So the money has not flowed in, the early development work has been slow, and the drugs are not ready to cope with this unprecedented level of demand.

Secondly, it’s easy for non-specialists like me to imagine someone just has to turn on a machine in order to pump out whatever synthetic products go into these drugs – but I understand it’s not like that.  Taking ZMapp as an example, manufacturers Mapp Bio explain that the humanised antibody proteins that make up the drug are grown using a low-nicotine tobacco plant as a host.  Once the plants mature, they are harvested and the antibody proteins need to be extracted, purified and tested before they can be made into a drug.  This is not a process of pulling a lever, it takes time to grow the basic components of the drug.  No matter how eager organisations may be to invest in this process now, it still takes as long as a tobacco plant to grow before you get any results.

Finally, in order for a drug to be produced on any significant scale it needs to be licenced, which means it first has to go through a clinical trial.  Clinical trials happen in a number of stages – the first stage tests the drug for safety using up to 100 health volunteers.  That is achievable – if the drug is produced.  Health volunteers are relatively easy to come by.  But the second, third and fourth stages of the trial require larger numbers of ill people, because they are not testing only the safety of the drug, but also the effectiveness of the drug in treating the disease it is designed to treat.  To conduct a phase two trial, usually several hundred people will be involved.  The problem with Ebola is, you only have these people available in the context of an outbreak, and no one knows when or where an outbreak may take place.  There is no precedent to the scale of this outbreak – there have already been more than five times the number of cases that any previous outbreak of any Ebola strain has accumulated.  This outbreak could provide a sufficient number of cases for a clinical trial to progress – but no one could ever have known to be prepared.

Ethics and experimental treatments

Last week the WHO approved the use of experimental treatments in the Ebola outbreak in West Africa.  There had been mounting pressure about this issue, particularly after three leading Ebola experts called for the WHO to take the lead in agreeing the use of such treatments the week before (http://blog.wellcome.ac.uk/2014/08/06/experimental-medicine-in-a-time-of-ebola/).  The report of the 12-member panel that the WHO convened is now publically available, so let’s break down the dilemma …

What do you mean, experimental?  Before treatments obtain a licence, they go through a lengthy process of experimentation and testing.  Usually they are first tested on tissues in a lab setting – no live creatures involved.  They may then be tested on animals, and usually drugs must be successfully tested on two types of animals before they go forward to clinical trials in humans.  The WHO has expressed a preference for experimental drugs that have shown promising results on primates in the case of Ebola treatments that may be used in this outbreak.

In order to prove their worth, the bottom line for new drugs is that they must be safe and efficacious.  Safe means that they don’t hurt people – a few minor side effects are one thing, but we need to know if a drug might cause an unacceptable level of harm compared to the potential for good.  Efficacious means that they work.  The dilemma in the use of experimental Ebola drugs is that we don’t know, in humans, whether they are safe and efficacious.

Why should they be used?  Taking a drug when we don’t know either whether it will work or what negative effects it might have is a risk.  The question is, is it a risk worth taking?  The WHO has decided that in this instance, such treatments may be used on compassionate grounds (i.e. outside of a clinical trial), because the scale of the outbreak is unprecedented, and health systems in the affected countries are already way beyond their capacity.  At the end of the day, the only way of finding out whether an Ebola treatment is safe and efficacious is during an outbreak – and some of the drugs under development are ready for human testing.

What are the conditions?  Informed consent and understanding of the risks is vital for patients, their families and carers, and medical personnel administering the drugs, along with management of communities’ expectations more widely.  The capacity to care for the patient who is receiving the experimental treatment fully must be there, including monitoring and treating any side effects.  The panel asserted that there is a moral duty to collect scientifically useful information during the use of untested treatments that can be used to understand how safe and effective they are in the interim until clinical trials can be conducted.  Finally, the use of experimental treatments should not distract attention from the public health interventions which are the main means of controlling the outbreak.

Who gets them?  Perhaps the thorniest issue of all – technically, the WHO has agreed to the use of experimental treatments for possible treatment of those that are infected, for people who have been exposed to the disease but have not yet shown any symptoms (post-exposure prophylaxis), or for people who may be exposed (pre-exposure prophylaxis).  In reality, the supply of these drugs is very limited, so decisions need to be made about who gets it and who does not.  The main debate is about whether health care workers should be given priority – the main ethical principles for are reciprocity (after all, they are putting their lives at risk by treating Ebola patients) and social usefulness (we need them to fight the outbreak).  But where does this leave victims of Ebola in communities that have been affected?

It makes you wonder, under what circumstances would you agree to someone putting a drug in your body when no one knows whether it will work or the damage that it might do?  I don’t have the answer for myself, but I do know I would want to be given the choice.

No cure

I clearly remember the first time I heard of Ebola.  It was 2012 and I was in Juba, South Sudan with my husband.  He is a medical doctor, and was working in Juba Teaching Hospital, where there is an office that we were both using.  I was doing research on South Sudanese mothers’ experiences of medical care.  That summer there were a couple of Ebola cases in Uganda, and this made the news (Al Jazeera has been my first choice of news providers since that time because I was so impressed with the breadth of coverage).  At the same time, a rumour was going round the hospital where we were working that there was an Ebola case there in Juba Teaching Hospital.  As with most rumours, it turned out to be a false alarm.  However (after my hubby explained what Ebola was), I remember the disconcerting feeling of powerlessness from potentially being in the presence of an incurable, deadly disease.

Until I heard about Ebola I never realised how invincible I thought I was.  Don’t get me wrong – I know I could get hit by the proverbial lorry or some similar terminal mishap.  I acknowledge accident and injury as a real and serious danger.  But in relation to disease?  I am relatively young, fairly fit and healthy, and having lived the majority of my life in the Western world I expect to be immunised, to take prophylactic treatment or, should I contract a disease, to be provided with the latest treatments, without excessive cost (if any), and for these to be effective.  The thought of there being a disease with no cure and that we understand so little about out there seemed dark, mysterious, and incredibly unnerving.  As I experienced this reaction I was simultaneously painfully aware of the life of privilege my reaction betrayed.

When I was in Monrovia a few weeks back, I heard exasperated colleagues report that some unscrupulous people had been selling an Ebola ‘vaccine’ in the market, conning anxious laypeople with a false hope.  Perhaps even if you live in a context where the treatments you need for the diseases in my expansive ‘preventable/treatable’ category may be unavailable or unaffordable to you, there is something unnerving at the thought of a disease that no one could treat or cure.

The real cost to health

The number of cases continues to climb – as of 13th August, there have been 786 cases and 413 deaths in Liberia – that we know about. But I can’t help but think, horrific as the reality behind these figures is, it is the tip of the iceberg in relation to the impact of this outbreak on health in Liberia.

I was shocked to learn whilst in Liberia that the country has only around 150 of its own doctors – for a population of over 4 million people. At the best of times health care provision is limited – and many of these are working without all of the drugs or equipment they might need. It’s hard to imagine how demoralising it is for medical professionals to live in a context of overwhelming need and the skills but not the resources to help.

Unfortunately doctors and other medical professionals are one of the high-risk groups of contracting Ebola, due to their necessary contact with bodily fluids of patients with the disease. In fact, WHO Director General Margaret Chan reported on 12th August that so far in the outbreak as a whole 170 medical professionals have been infected, and 80 of these have died. That is a devastating blow to the health capacity of the region.

What about outside support, you may ask? Medecins Sans Frontieres has a huge presence in Liberia, but even this week their Emergency Coordinator in Liberia, Lindis Hurum, has announced,

“We have exhausted our available pool of experienced medical staff and cannot scale up our response any further ... We are Doctors Without Borders but not without limits.”

This of course is bad for the management of the Ebola outbreak, and we know that there are many more cases that never reach medical care than those that we know of. But what strikes me is, the usual health challenges that Liberia experiences are significant, and they have not gone away on account of the Ebola crisis. For example, the prevalence of Malaria is 50% higher in Liberia than in the Africa region as a whole, and it is the biggest killer of under 5s in the country. TB prevalence is more like 65% higher in Liberia than in the rest of Africa. Poor roads make road accidents common, often resulting in trauma. Where do you go, when health facilities are either overwhelmed with Ebola victims, or, in many cases, closed? Who will treat you when health workers are sick, dead, have fled due to fear and lack of payment for their services, or are busy in Ebola treatment facilities?

I wonder whether when all of this is done, someone will calculate how many extra lives were lost as a consequence of Ebola, even those that never contracted the disease? I wonder how many years health systems will be set back? 

How to stop an outbreak

What do we do when a deadly contagious disease grips a country?  On the assumption that Jack Bauer does not have all the answers (which, as a viewer of the TV series ‘24’, I willingly admit is tenuous), today we’re going to look at some of the elements that are critical to containing an outbreak of Ebola Virus Disease, which will lay the groundwork for understanding some of the problems that are being faced in Liberia and other West African countries:

1.       Trained and equipped medical staff – It’s vital that the cases of Ebola are managed properly.  This means barrier nursing techniques, including the wearing of protective clothing (such as masks, gloves, gowns, and goggles), using infection-control measures (such as complete equipment sterilisation and routine use of disinfectant), and isolating patients with Ebola from contact with unprotected persons.  In order to achieve this, the people need to be there in the first place, to be trained to recognise the symptoms of Ebola, to have the facility to test and confirm/disconfirm suspected cases, and to have the clinical environment and equipment that they need in order to achieve the standards above in the mean time.  With no exceptions.

2.       Containment – Early detection and isolation of cases is essential to stop Ebola spreading.  Ebola is NOT airborne (and don’t believe what you read to the contrary), and infection relies on the direct contact with bodily fluids from infected people who are displaying the symptoms of Ebola.  The risk of contagion increases the more advanced the disease is, so if you can identify people infected with Ebola in the early stages, not only does this increase their personal chances of survival, it also means you can isolate them and thus minimise the number of other people who come into contact with infected bodily fluids.

3.       Contact tracing – Once Ebola cases are identified, you need to list everyone who may have come into contact with contaminated bodily fluids and thus be at risk of contagion.  These ‘contacts’ must be traced, must be provided with information and counselling, and need to monitor their temperature and other signs of symptoms to ensure early detection.  I have heard it said that about one in ten contacts is likely to develop Ebola Virus Disease.

4.       Sensitisation – People need to know about the risk of Ebola - in perspective with other health risks that they may encounter, such as the much more common Malaria and Typhoid – and what to do about it if they or someone they care for experiences symptoms.  Something that was impressed upon me by the District Chairwoman of Bushrod Island in Monrovia is how fundamental education is to all aspects of life, peace and development in Liberia.  People need to understand how to identify the disease, how it is communicated, and what action to take if any symptoms are exhibited.  This needs to be common knowledge for Ebola to be contained.

5.       Cooperation – Perhaps this is the hardest battle to win.  People need to cooperate, 100%.  Staff need to adhere to the standards of hygiene that barrier nursing requires.  People who are suffering from Ebola-like symptoms need to subject themselves to the authority of medical agencies that require their containment.  Contacts need to be found, and to comply with the monitoring of their health.  Communities need to acknowledge that the disease exists and to support measures that are put in place to protect them.

A small disclaimer: I am not a public health expert.  Nevertheless, you may begin to imagine why agencies in the UK reassure us that an outbreak on the scale we are witnessing in Liberia and beyond would have less chance to take hold in the UK.  The world is not a fair and equal place.

"In the news"

A few days after I arrived back in the UK I received emails from my PhD supervisors, two fearsomely wise and effective women, noting that Ebola was in the news a bit more and advising me to monitor the situation in case it affects my plans to return to Liberia for my fieldwork.  The trouble is, (and forgive me for the social research talk) “being in the news” is not a great quantitative indicator of the severity of a situation.  As we all experience daily, sometimes things are “in the news” which are all hype, and sometimes things that really should be “in the news” seem to be forgotten.  I needed to find another way to track whether the outbreak in Liberia really was getting worse, or whether it was just getting more attention.

From the beginning of the outbreak, the World Health Organisation (WHO) has been tracking and providing updates about what is happening in West Africa.  I’d like to take this moment to say what a fantastic organisation I think the WHO is – we don’t recognise the work they do protecting life enough.  Anyhow, if you take their reports monitoring the outbreak, along with outbreak reports produced by the National Travel Health Network and Centre (NaTHNaC), you can produce a nice little data set.  The reporting has got more precise as time has gone on, so I have taken the figures from early June to demonstrate the trends in the numbers of cases and deaths.

So what does this tell me?  Since around the 20^th July the number of cases (and, therefore, deaths) seems to be rising more rapidly.  But how widespread is this?  The outbreak in Liberia began in a very specific area – the Foya District - in the north west of the country, and I have no reason to go there.  Well, the nice people at www.medicalteams.org have shared this map, produced by the Ministry of Health and Social Welfare, which shows that 9 of Liberia’s 15 counties are now affected.

So, in summary, yes – it is getting worse.

Introducing Liberia

When I chose Liberia as the field site for my sociology PhD research earlier this year, it wasn't uncommon for friends to hesitate, before asking, “Where exactly is that?”  Those friends and family who knew a little more of the place would ask, “Is it safe now?”  They knew that just over ten years ago Liberia came to the end of a devastating civil war, which took a country that once stormed ahead in measures of development and placed it firmly back at the bottom of the pile – 175^th, to be precise, of the 187 countries included in the 2014 Human Development Index produced by the UN.

Three weeks ago I was in Liberia doing the final planning and preparation for my PhD data collection, with help from my collaborators in the Red Cross.  One of the first things a colleague said to me when I arrived in their Monrovia offices was, “You find us in the middle of Ebola.”  Already the Red Cross was mobilising in defence against the feared disease, applying every last ounce of force at its disposal to the colossal public health task, whilst frantically seeking the additional financial support it needs for this work.  Since I returned the outbreak has severely worsened, and the need that was already great is now spiraling.

People have heard of Liberia now.  Not because of the crushing beauty of the Atlantic crashing on 360 miles of pristine beaches and mangroves, not because of the global importance of the lush forests to biodiversity, not because of the vibrancy of Liberian-made fabrics that is known all over Africa.  Now friends and colleagues still ask me, “Is it safe?”  But they are not asking about human violence any more.  Ebola has made Liberia famous again.

To find out more about the work of the Red Cross in Liberia, click on the image of the motorbike to the right of this page.