Beating Ebola in a global village

By Anayo Unachukwu

While I was writing this piece, I received a news alert from the Washington Post, about the arrival to the US of Dr Kent Brantly, an American doctor, who was infected with Ebola while working in Liberia with a Christian missionary organisation — Samaritan’s Purse. His repatriation to his country was not without controversy. In recent times, there are perhaps fewer diseases that have been more polarising of the US public opinion as Ebola. The virus, although, lethal has a reproduction number (the average number of secondary cases arising from one infectious case in a totally susceptible population) of 1 compared to say measles, greater than 12.

When his repatriation to Emory University Hospital, Atlanta, was mooted, some talking heads went into overdrive. Some were very indignant and vociferous about the repatriation. While an equally significant number came down on the side of the repatriation.

The champion for vociferous group was the well-known ex-billionaire (who is usually one story short of a controversy and not one for missing an opportunity to criticise the present administration) Donald Trump. He fired the first salvo, which went viral, on his Tweeter feed: “Ebola patient will be brought to the US in a few days — now I know for sure that our leaders are incompetent. KEEP THEM OUT OF HERE!”

Not done with giving his unsolicited opinion, the next day he tweeted: “Stop the EBOLA patients from entering the US. Treat them, at the highest level, over there. THE UNITED STATES HAS ENOUGH PROBLEMS!” A Washington Post commenter in response to Trump’s evocative tweet rhetorically asked: ” ‘Treat them at the highest level.’ Mr Weird Hair thinks they should be hoisted into a tree? Or what?”

Given the moral panic that ensured, as a result of a free-floating atmosphere of paranoia generated by the vociferous group; saner responses came by way of a series of statements made by eminent researchers in infectious diseases, immunology and public health in the US — reassuring its citizens.

Meanwhile, across the Atlantic, on July 30 2014, the British coalition government held its first ever government emergency response (Cobra) meeting that was chaired by its recently appointed foreign secretary, Philip Hammond. This was in response to the total fatality from the virus since its current outbreak in February. As at the time, the number stood at more than 620 deaths. Cobra meetings are usually imperative on matters of national security. It was most surprising that the meeting became necessary — in spite of its chief scientific adviser, Mark Walport, having earlier given an interview to the Daily Telegraph where he informed that an outbreak in the British Isles was very unlikely. Although Walport did acknowledge the lethality of Ebola and its public health concerns and “the need for horizontal scanning” and “think about risk” and “managing the risk appropriately”.

A few days prior to the aforesaid developments, a Liberian-American, Patrick Sawyer died in Lagos, Nigeria, after being quarantined in a local hospital earlier with symptoms that were consistent with Ebola. It was the first reported case of Ebola in the country. This was unsurprising, given the recent outbreak of the virus in its neighbouring countries — where citizens enjoy no legal restrictions travelling within the economic region. But what was surprising was that Sawyer was allowed to board a transatlantic flight with multiple transits en-route to the US while harbouring symptoms consistent with Ebola.

The decision by the Nigerian government to suspend Asky flights in the country, while it investigates sequences and events surrounding the air travel of the deceased is a commendable public health measure. But it is uncertain if Nigeria has a robust coherent strategy to deal with an outbreak of Ebola, if one goes by its predilection for being mired in the muck of indecision on matters of public concerns and national security.

Further, Ebola couldn’t have chosen a more salubrious period to visit Nigeria, particularly at a time when its doctors — in public sector — have remained on strike with no end in sight, decades of poor investment in healthcare and medical research, derelict and dilapidated healthcare infrastructure, poor regulatory measures and derisory budgetary allocation and poor of capability within the sector. A country where attempts at healthcare reform have remained a Sisyphean task will only accentuate the virulence and epidemic reach of Ebola.

In parallel to these challenges are externalities such as poor education, lack of access to healthcare facilities, illiteracy and superstitions and suspicion of healthcare facilities, insecurity and instability in large swathes of its population, particularly in northern Nigeria and its un-policed porous borders.

An interconnected world
Most countries and its leadership are worried by the current outbreak of Ebola in spite of the fact that these countries may be distant from where the theatre of infection is wreaking havoc. Further, Ebola is a delicate, very slowly mutating filovirus with a very low reproduction number and it is not as contagious as bird flu and Middle East respiratory virus that has been reported in the US. Given its delicate nature, washing with soap and water — outside its host — renders it less contagious. Besides, evidence suggests that asymptomatic individuals are mostly non-contagious.

In spite of these, the current panic mainly in the developed world may unfortunately inform decisions and policies in response to the outbreak by their government, which may have practical implications in sub-Saharan countries. It can be argued that such a response may be understandable — irrespective of the facts. The recent outbreak has caused more fatalities than any previous outbreaks since it was first reported in two simultaneous outbreaks in 1976 in Nzara, Sudan, and in Yambuku, Zaire (now Democratic Republic of Congo). The latter was in a village close to Ebola River, where the name was derived. Further, the current strain — Zaire-strain — is more virulent than other strains. Besides, previous outbreaks have been confined to villages and rural Africa. Further, with the virus, one can’t have a good death, given that the infected patients die an isolated painful death — physically and psychologically separated from their families and loved ones.

Beyond factors intrinsically linked to the virus, are some externalities.

Many countries, particularly western nations are concerned about the lack of coherent strategic response by the governments in sub-Saharan Africa where mortality from the virus continues unabated. Further, their concern and the scare may stem from value judgment and crisis of confidence on the institutional capabilities, capacities, effectiveness and expertise intrinsic to healthcare systems in the affected countries. Decades of neglect, poor regulation and investment and the degradation of their health infrastructure tend to lend some credence to those negative emotions and evaluations. To drive home the point, it is most concerning to note that Africa has a mere 3% of the global health workforce while it accounts for 24% of the global burden of disease. This disconnect is most disturbing and requires urgent attention by its leaders and policymakers.

All things considered, it is most unsurprising that in moment of crisis, where confidence in the system is in short supply, heuristic appraisal and perception inform loose thinking and responses.

Further, the democratisation of travel has made it possible for people to move within and across continents, countries and regions within a matter of a few hours to a couple of days. Incubation periods of most infectious diseases last longer than these. Suffice it to say that advances in aviation technology and the industry and globalisation have made the world a very inter-connected space with obvious opportunities and challenges. An individual may contract an infection from one part of the world and spread it to a very distant land in a matter of days while incubating the pathogen without discernible symptoms.

Given the foregoing, public health concern or other events with socioeconomic and political implications can easily metastasise to places far flung from the origin of such perturbation. Some governments and their policymakers — particularly in the west — notwithstanding the foregoing are loath to view the interconnectedness from the optics of current reality. Investments in infectious diseases research have nose-dived in most of these countries and funding for infectious diseases clinics has drastically reduced as part of a drive for efficiency savings. The private sector has not fared any better, particularly the pharmaceutical industry that is well-known for its Darwinian approach to portfolio management. For years, it has rechanneled resources and infrastructure for research in infectious diseases to more lucrative pipelines.

In a very strange way, Ebola has reminded us about the fragility of life. And our common humanity and the interconnectedness of our global village should inform our public policy and humanitarian advocacy. In order to effectively tackle this immediate public health challenge, there should be local co-ordination and co-operation — taking advantage of information and expertise on the ground — and support from the international community. In the intermediate and long term, there needs to be an enriched space for comprehensive collaboration to help with the sharing of information, knowledge and expertise and the creation of institutional capability and capacity that encourages proactive responses.

Anayo Unachukwu is a psychiatrist based in Wiltshire, UK, and holds a Master of Law (LLM Medical Law) degree. He is interested in medico-legal issues, medical ethics and the impact of inequality on health.