Ebola rules

The ebola epidemic in West Africa continues to rage out of control. So far reported cases have topped 4,200 and are continuing to climb every day. More than 2,000 people have also died from the disease.

There seems little doubt, however, that such figures severely underestimate the real number of cases and deaths. Predictions suggest that if the epidemic is not brought under control we may well be looking at more than 20,000 cases within the next few months and that it may take 6-9 months for the epidemic to disappear. It is a chilling thought.

But why have we struggled over the last three or four months to contain the epidemic? In theory at least ebola should be easily contained. The disease has a relatively long incubation period, about 10 days on average and people who have been exposed to the disease are not actually infectious until actual symptoms appear. In addition, the disease does not spread easily among people.

Compare this with influenza or SARS which had much shorter incubation periods and which spread rapidly via airborne transmissions.

So why have we not managed to bring ebola under control?

The normal response to stop outbreaks of infectious disease is to institute comprehensive surveillance and contact tracing procedures followed by the isolation of cases and possible contacts, the establishment of specific health care facilities, and if at all possible mass vaccination of people. Why has this not been successful in West Africa?

Well, in the first instance local fear and mistrust have been so widespread that many ill or exposed people have refused to report to health authorities or have been hidden away by anxious relatives who fear that removal is akin to a death sentence. Others from areas where a case has become known have simply fled into the forest. Such has made contact tracing and the identification of actual cases at times almost impossible. Public protests and a lack of cooperation have added to the problem as people have reacted violently against the intrusion of "foreign outsiders" who they somehow believe are responsible for the epidemic.

As well, contact tracing is severely hampered by the totally shambolic data system available in much of West Africa, where lists of people's addresses or workplaces are either not available or stated in terms such as "lives near forest" or lives and works "near end of road". Add all this to the fact that there are not enough people engaged in contact tracing to successfully complete the job and it is not difficult to understand why ebola is becoming so hard to control. Finally, there is of course no specific cure for the disease and the recently developed vaccine in the USA cannot be made widely available.

Throughout West Africa the general community reaction to Western involvement and attempts to control the outbreak has often been hostile and generally uncooperative. Local people remain highly suspicious of health care workers and have avoided any sort of contact. Public fear, anxiety and hysteria rule and many people fear that if they report a case or possible contact they run the risk of being ostracized by their local community. The practice of isolating and quarantining whole villages or city suburbs has also led to an outburst of anger and mistrust among local communities with many people claiming that they may well die of hunger before they die of ebola. Quarantine has had a major effect upon the rural economy with many farms 'locked down' and bereft of labour. The result has been a substantial decline in agricultural productivity and supply. Add to this the fact that many multinational firms have substantially cutback on staff and activities and you have a scenario of economic decline.

In times of epidemic crisis when modern medicine is perceived to offer no defense or respite people often reach back to embrace local cures, traditional measures and popular medicines. In West Africa this has happened when local rumours that certain local products or practices offered a defense against ebola encouraged many people to begin drinking large amounts of hot salt water, coffee and holy water or eating large amounts of raw onions.

So what can be done and how are we going to contain this outbreak?

In the first instance there needs to be more people on the ground involved in the fight against ebola. One of the basic problems in trying to contain this outbreak was that initially the international community responded very slowly revealing perhaps just how poorly constructed and unready our global response systems to major epidemic outbreaks are.