Medical Examiner

Here’s Where We Stand With Ebola

Even experienced international disaster responders are shocked at how bad it’s gotten.

Health workers push an Ebola patient who escaped from quarantine from Monrovia’s ELWA Hospital into an ambulance in the center of Paynesville, Liberia, on Sept. 1, 2014. The patient, who wore a tag showing he had tested positive for Ebola, held a stick and tried to get away from doctors when they arrived on the scene attempting to catch him.

Photo by Reuters

It’s nine months into the biggest Ebola outbreak in history, and the situation is only going from bad to worse. The outbreak simmered slowly in West Africa from December 2013, when the first case was retrospectively documented, through March, when it was first recognized by international authorities. It began gaining momentum in June and throughout July. Now, terms like “exponential spread” are being thrown around as the epidemic continues to expand more and more rapidly. Just last week, an increase of 700 new cases was reported, and the case count is now doubling in size approximately every three weeks.

Already, the number of cases (approximately 5,300 as of Sept. 18) and deaths (2,630) has dwarfed the total number of cases and deaths from every reported Ebola outbreak in history—and those are only the cases that we know about. Here’s where we stand with Ebola right now.

The situation on the ground

By all accounts, it’s understandably miserable everywhere Ebola has hit, but even experienced international disaster responders have been shocked at how bad it has gotten. A Doctors Without Borders worker in Monrovia, Liberia, named Jackson Naimah describes the situation in his home country, noting that patients are literally dying at the front door of his treatment center because it lacks patient beds and assistance; the sufferers are left to die a “horrible, undignified death” and potentially infect others as they do so:

One day this week, I sat outside the treatment center eating my lunch. I saw a boy approach the gate. A week ago his father died from Ebola. I could see that his mouth was red with blood. We had no space for him. When he turned away to walk into town, I thought to myself that this boy is going to take a taxi, and he is going to go home to his family, and he will infect them.

When health care workers aren’t available, or when patients are too fearful to take loved ones to a clinic, it falls to those closest to the ill to nurse them. This has wiped out entire families, “prey[ing] on care and love, piggybacking on the deepest, most distinctly human virtues,” turning caregivers into victims as the virus passes among siblings and parents, from one generation to the next.

Health care workers who are treating the sick are dying because they also lack basic protective equipment, or because they have been so overwhelmed by taking care of the ill and dying that they begin to make potentially fatal errors. They have gone on strike in Liberia because they are not being adequately protected or even paid for their risky service. Hearses have been commandeered as ambulances; motorcycles are used to transport patients long distances, putting drivers at risk of becoming the next victim.

Fear and misinformation are as deadly as the virus itself. Eight Ebola workers were recently murdered in Guinea, in the area where the virus first came to the world’s attention in March. Liberia’s largest newspaper featured a story describing Ebola as a man-made virus being purposely unleashed upon Africans by Western pharmaceutical companies. Reports abound of doctors and other workers being chased away, sometimes violently, by fearful families. A second outbreak was triggered in Nigeria after an infected diplomat broke quarantine and fled from Liberia to Port Harcourt.

So far, other West African countries have been largely spared. Senegal experienced one imported case in late August, but to date other contacts have tested negative for the virus. Ivory Coast is watching closely and working to keep the virus out of the country. Perhaps the most extreme measures are currently being taken in Sierra Leone, where the country has been under a lockdown for three days to track cases of infection and minimize transmission. The country’s 6 million residents were ordered to stay indoors while volunteers went door-to-door to educate citizens, document new cases, and remove bodies.

The response

To date, nongovernmental organizations have largely been leading the fight against Ebola in West Africa. Doctors Without Borders (also known by its French name, Médecins Sans Frontières, or MSF) has led the international battle against Ebola, and where its workers have had success in the past, they have been completely overwhelmed now for months. MSF International President Joanne Liu has made multiple appeals to the United Nations, begging for additional assistance, noting on Sept. 16:

As of today, MSF has sent more than 420 tonnes of supplies to the affected countries. We have 2,000 staff on the ground. We manage more than 530 beds in five different Ebola care centres. Yet we are overwhelmed.  We are honestly at a loss as to how a single, private NGO is providing the bulk of isolation units and beds.

The plea has fallen on sympathetic ears, but the response has been slow and insufficient. The United States has answered the call to some extent, promising 3,000 military personnel and up to $750 million in aid. Even this massive amount is less than what the World Health Organization has called for: a minimum of $1 billion, and even that will only keep infections contained to the “tens of thousands.”

No one has sounded the alarm more clearly or critically than journalist Laurie Garrett, who wrote about Ebola in her 1995 book The Coming Plague. Writing for Foreign Policy, she has denounced the international response and lack of coordination, criticizing individual countries as well as the United Nations, World Health Organization, and the World Bank, noting that the world “just doesn’t get it” when it comes to Ebola.

The virus

If there can be a faint silver lining to this outbreak, it’s that researchers have been able to study the evolution of the virus in a way no previous Ebola epidemic has allowed. With thousands of cases documented to date, investigators have been able to track mutations in the virus’ RNA genome—and they found hundreds of mutations just in viruses examined before the publication of a paper in Science in August. In a tragic footnote, five of the authors of this paper died of Ebola during this outbreak.

While we do know that the virus is mutating, what remains murky is what those mutations are actually doing in patients. Genomic data itself is really only as good as the epidemiologic information that goes along with it, such as patient location, outcome of infection, symptoms exhibited, familial transmission patterns so it can be traced back between family members or members of the same geographic area, etc. Given that the outbreak has been so explosive and understaffed, much of this data may be lost, and it’s estimated that almost half of all those infected probably aren’t even reporting to hospitals—unfortunately limiting the conclusions of some of these genetic studies.

However, we do know that the risk that this outbreak may spawn an airborne Ebola virus is still incredibly tiny. Virologist Vincent Racaniello sums up the history of viruses mutating to a novel route of transmission, noting, “There is no reason to believe that Ebola virus is any different from any of the viruses that infect humans and have not changed the way that they are spread,” and that “the likelihood that Ebola virus will go airborne is so remote that we should not use it to frighten people.”

The big concerns

Even without an airborne form of Zaire Ebolavirus, we still have plenty to be concerned about. Models have suggested that this outbreak could go on for several more months at a minimum. The worst-case situation suggests that half a million cases are possible before the outbreak is finally brought under control. New research proposes that the current outbreak is so different from past Ebola epidemics that modeling is simply not informative, and “as a result, we are not in a position to provide an accurate prediction of the current outbreak.”

Besides the incredible potential number of lives lost, a huge concern is the destabilization of the affected countries—and even of those around them that have not shown any cases of Ebola. WHO Director-General Margaret Chan noted that this outbreak “is a social crisis, a humanitarian crisis, an economic crisis, and a threat to national security well beyond the outbreak zones.” Partly in response to the testimony of Chan and others, the United Nations announced the establishment of an emergency mission to fight Ebola. Countries were also asked to lift travel bans to the affected countries, which have made it more difficult to move supplies in and out of the area.

While 5,300 cases may not be a lot in the grand scheme of things, hospitals and clinics have been crippled, and mortality rates in these countries may be affected beyond just the Ebola virus. Patients who have other ailments, pregnant women looking to enter hospitals and clinics to give birth or to bring in ill children with non-Ebola-related diseases have been turned away. Crops are not being harvested or transported, making hunger an issue equal or greater to Ebola in many areas.

Finally, all of this is only examining the West African Ebola outbreak. Ebola also re-emerged in the Democratic Republic of the Congo in August; to date, there have been at least 60 cases in that country and 35 deaths. With all of the concern about West Africa, much less attention and aid has been given to the DRC, which has a much more extensive history of Ebola epidemics, mainly in rural areas. It is hoped that history and experience will more quickly bring the outbreak there under control.

The coming months

Even with massive international intervention, the situation will still worsen before it improves. The influx of funds and assistance from the United States and other countries is certainly welcome news, but it remains to be seen exactly how that will be allocated, who will be in charge, and how coordination will be established. This will be a long-term effort, and even after this Ebola outbreak has been extinguished, additional doctors and nurses will need to be trained to replace those that have been tragically lost in this epidemic. Some of Ebola’s victims will survive, but they and their families may face harsh stigma in their hometowns. It may take a year, but this fire from the pit of hell will eventually be extinguished. At what cost to human life, we do not know yet.