The difficulty of treating, and containing, Ebola locally

Some people have questions about the Ebola outbreak in West Africa. Questions like: Why can’t patients be treated there vs. transporting them to other countries? Why is the outbreak so difficult to control? Those are reasonable questions. Here is some additional information that may help to answer them to a degree.

I’m in contact with a few physicians who have been on the ground in Liberia treating patients there. One returned as recently as 6 weeks ago. Others have been in the area sporadically over the years volunteering to treat patients, teach local doctors, help with organizing clinics, etc. I’ve gotten an idea of what they, and the population, are facing there. Let me try to make a comparison between what things are like here and there.

Let’s take a look at a typical US patient. When someone in the US isn’t feeling well, in many cases, he has several options. He drives, is driven or takes an ambulance to a medical provider or clinical site. He can see his PCP or another doctor in that doctor’s office. He can go to a medical clinic. Or an urgent care. He might go to an emergency room. In some cases, depending on the problem, he might be able to go to his local public health department. He gets seen by the doctor who may give him a prescription(s), order blood tests, medical imaging, cardiac testing, send him to a hospital for more advanced treatment, send him for surgery, etc. He’ll get his prescriptions, tests, referrals and recover.

The Ebola virus, courtesy of Shutterstock

The Ebola virus, courtesy of Shutterstock

Now, let’s make this patient a Liberian in a village outside of Monrovia. He gets sick. If he can escape his family responsibilities (working at his job, getting food for the family) he might be able to walk several miles to the clinic, if there is a clinic in the area. He may get there only to find that it’s closed or that the doctor is away. He has no access to a phone to call the clinic in advance. That’s assuming that the clinic itself has a phone for him to call.

But let’s say that he gets there and there is someone to examine him. In this area, doctors are scarce, so he may be examined by a nurse. If the diagnosis is malaria, he can get some anti-malarial medications, if the clinic has any. If not, he might be told to come back in a week to see if the medicine is available then. Blood test? Maybe he can get it drawn at the clinic. Some of the larger clinics can do very limited, simple testing. Most can’t But the clinic has no electricity so the blood can’t be refrigerated till it gets picked up to be taken off for testing at the hospital. If there is a courier available to transport it. Medical imaging? No. Cardiology services? No. Perhaps, if he’s seriously ill, transport to the local hospital can be arranged. Maybe that day or in a day or two.

Now, imagine how difficult it would be to adequately treat a seriously ill Ebola patient in that setting. No electricity, no running water, no reliable communications or transport, no plumbing, no isolation ward, healthcare workers with minimal training, limited protective gear, no facilities to incinerate contaminated equipment/fluids/supplies. Little clinics like these can even be out of aspirin for weeks at a time. No, or limited equipment to start an IV. No IV fluids (Ebola patients can go into shock. Shock can require a lot of IV fluids. And, since the Ebola patients bleed, they need transfused with blood and blood products. Those aren’t available at the clinic.) IV medications may be needed to help support blood pressure, too. Not available in this setting. Healthcare personnel are afraid of taking care of Ebola patients since they are working under primitive conditions and constrained by lack of facilities and equipment.

Add to that scene, the steady influx of other patients to the clinic. The patients with malaria, gastroenteritis, typhoid, other infections, wounds, broken bones, trauma, surgical conditions, ill children and babies and the occasional Ebola patient. Trying to take adequate care of an Ebola (or other seriously ill) patient under those circumstances? Virtually impossible.

What about containing Ebola in Africa? How difficult might that be? Here are a few glimpses of some of the possibilities.

A mother’s baby has Ebola. The baby has diarrhea and is vomiting. He’s feverish, too. Mom needs to wash her clothes and the cloths she’s clean the baby with. She also wants to bathe the baby and try to cool him off with a bath. She fills a large basin and washes the Ebola-infected clothes exposing herself to the virus. She throws the water outside of the door. It forms a puddle that the other children play in. Or, she takes the clothes and baby to a nearby stream or river to wash. Just out of sight, downstream, children are playing in, and drinking, the water.

The Mother becomes infected and subsequently dies. The mourning relatives wash and prepare her body and kiss her goodbye. In the process becoming infected with Ebola themselves.

Fruit bats (carriers of Ebola) often nest in the ceilings of houses and huts. Their excrement falls on the floor. The babies and toddlers get the bat feces on themselves and transfer virus to their mouths and eyes. Or children playing in a local cave where fruit bats roost, floor covered with bat guano.

To supplement their diets, the people often eat “bush meat.” That’s a generic term for pretty much any animal that they can trap and kill. This can include fruit bats, pigs, antelope, various species of monkey and other animals that can be infected with Ebola. Skinning and cleaning these animals can expose people to the virus. Also, if the meat is undercooked they can be exposed, as well. Remember that there is no running water in much of this area. So, after skinning the animals, there may be no place to wash off the animal’s blood.

Similarly, with no waste treatment facilities, people with diarrhea from Ebola nay be squatting urgently wherever they can. They can contaminate their hands and then greet others, handle food, pick up children, etc. and spread the virus along that way.

When dealing with an outbreak in somewhat more advanced countries allows for better communication and education options. Here we can reach out to people via TV, radio, social media, newspapers and other print media, videos and by other means. In these areas of Africa, the people are mostly poor and uneducated or under educated. Some are illiterate. They don’t have access to television, radio, social media, smart phones. The local governments have to try to do teach and spread information virtually on foot, visiting people in markets, in their homes and other places. It has to be done individually or in small groups because, in many areas, large group meetings have been banned. Liberia has about 4,000,000 citizens scattered over about 40,000 square miles. Additionally, English is the predominant language. But there are dozens of other tribal languages spoken there. Not everyone has a good grasp of English. Just putting up posters in English would still leave some people uninformed about the nature of Ebola.

Now visualize the difference if we needed to limit an outbreak in a country with a better infrastructure. That country would have the physical facilities that Liberia (or Sierra Leone or Guinea) lacks. Electricity, tap water, waste disposal/sanitation, transport, supplies, trained staff, medications, support services, advanced medical devices, etc. It would be easier to communicate with large numbers of people quickly via social media and other routes. A better educated population that is more literate would be easier to educate about the hazards of Ebola. The country would have many more doctors and healthcare personnel on site. More clinics and hospitals to diagnose, admit, isolate and treat patients adequately. A better economy to help deal with the costs of an outbreak. Having those factors in place, would make quarantine and treatment much easier than it is in a third-world country.

So when people demand that Ebola patients be treated where they are infected, they may not realize the problems and complexities of doing so where they lie ill. Similarly, when they are puzzled why the spread is so difficult to control, they may not realize many of the underlying reasons for it.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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  • jorgemandrews

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  • Hue-Man

    Another rich country process that would restrict the transmission of Ebola is “use once and throw away” – syringes, surgical kits, IVs, etc. With medical supplies in such short supply in these parts of Africa and with the lack of access to water and electricity, all of these supplies may be reused and result in further infections. Bed linens, gowns, masks can also be added to the list.

    Contaminated IV injections have been proposed as the reason HIV and Hepatitis C spread so quickly in Africa in the early 20th century and its subsequent spread to Haiti. http://en.wikipedia.org/wiki/History_of_HIV/AIDS#The_injection_campaigns_against_sleeping_sickness

  • http://www.americablog.com/ Naja pallida

    There hasn’t been any specific scientific verification that fruit bats are actually the primary reservoir, just hypothesis. After the original outbreaks of Ebola, the surrounding area was scoured and every single living thing that could harbor a virus was collected and tested, right down to the cockroaches, and they found no species with the virus. But bats experimentally infected in the lab often remain asymptomatic, making them the most likely reservoir.

    A study in Bangladesh, trying to determine a potential geographic range for Ebola found the fruit bats there had antibodies to both Ebola Zaire and Reston, but no virus. Gorilla corpses in Africa found to have died from Ebola, were tested and found to have had more than one variation of the virus, so it’s likely they were coming into contact with multiple infection sources – namely eating fruit dropped by fruit bats. Bats can migrate thousands of miles in a year, making tracking down a singular potential source very difficult, if not impossible. Pretty much any other mammal can become infected though.

    Even knowing that bats are the primary transmission source, there isn’t really anything that can be done about it. Hundreds of plants rely on fruit bats for pollination and seed dispersal, including commercially produced plants, like agave and bananas. Reducing fruit bat populations would be seriously detrimental to the ecosystem. Many species are already at risk because of habitat destruction.

    When it comes to human contact with Ebola, it almost always comes via pigs or non-human primates, even though fruit bats are sometimes consumed as bush meat.

  • http://www.rebeccamorn.com/mind BeccaM

    Disconcerted, sure — they do need more stringent enforcement of their own procedures.

    And yet, despite the mishandling of anthrax and smallpox samples, we have not had an outbreak of any of the diseases they are researching now or in the past due to CDC or NIH malfeasance or incompetence.

  • caphillprof

    You shouldn’t presume

  • GarySFBCN

    John and Mark, thanks for all of these posts about Ebola.

    Is the fruit bat the only non-human reservoir of the Ebola virus?

  • GarySFBCN

    So I presume that you’ve never gotten any vaccinations because of ‘public discourse’ ? That may be an unfair conclusion, but has you say, “fairness is irrelevant.”

    Sorry, you sound like Rand Paul.

  • caphillprof

    You are not paying attention to the public discourse. A lot of things today are not fair but fairness is irrelevant. It remains true that the establishment as a whole has been shown to be lacking and under those circumstances trust us is less than reassuring.

  • docsterx

    That’s a decidedly unfair remark. There is NO correlation between what occurred with anthrax and the epidemiologists, researchers, physicians, technical specialists and others who are working on Ebola.

    At the CDC, many people work in their own, specialized areas. A researcher specializing in filoviruses would rarely even think of bacterial pathogens and would hardly be involved with something like anthrax. Some of the people working on Ebola are epidemiologists who go to areas of outbreaks and track cases, do interviews, collect statistics and have nothing to do with cataloging/storing/maintaining samples. Especially samples of organisms outside to their own specialty areas.

    The CDC (and the NIH, which was also partially involved in the missing samples incident) has done decades of outstanding, groundbreaking research, work on prevention, quarantine, education, training and is recognized world-wide. You are slandering people who have spent their lives working to help other people be safe and well. You owe the CDC, NIH and their personnel an apology.

  • caphillprof

    One does not need to be right wing to be disconcerted about the self-same medical establishment assuring about the isolation of ebola patients when only weeks ago they couldn’t account for anthrax and other pathogens in their alleged control.

  • bkmn

    Great summary of why Ebola is not likely to cause an epidemic in the US and other developed countries. Too bad most of the uneducated right wing freaks will never venture here to read it.

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