rfmcdonald | [LINK] Paul Farmer on Ebola in Africa (Reply)

Doctor Paul Farmer, whose sensitive and insightful book AIDS and Accusation on the Haitian AIDS epidemic I reviewed in 2006, has a diary article up at the London Review of Books recounting his experiences of Ebola in Africa. As he notes, if Ebola is an epidemic, is it an epidemic defined--created, even--by extreme poverty.

Both nurses and doctors are scarce in the regions most heavily affected by Ebola. Even before the current crisis killed many of Liberia’s health professionals, there were fewer than fifty doctors working in the public health system in a country of more than four million people, most of whom live far from the capital. That’s one physician per 100,000 population, compared to 240 per 100,000 in the United States or 670 in Cuba. Properly equipped hospitals are even scarcer than staff, and this is true across the regions most affected by Ebola. Also scarce is personal protective equipment (PPE): gowns, gloves, masks, face shields etc. In Liberia there isn’t the staff, the stuff or the space to stop infections transmitted through bodily fluids, including blood, urine, breast milk, sweat, semen, vomit and diarrhoea. Ebola virus is shed during clinical illness and after death: it remains viable and infectious long after its hosts have breathed their last. Preparing the dead for burial has turned hundreds of mourners into Ebola victims.

Many of the region’s recent health gains, including a sharp decline in child mortality, have already been reversed, in large part because basic medical services have been shut down as a result of the crisis. Most of Ebola’s victims may well be dying from other causes: women in childbirth, children from diarrhoea, people in road accidents or from trauma of other sorts. There’s little doubt that the current epidemic can be stopped, but no one knows when or how it will be reined in. As Barack Obama said, speaking at a special session of the United Nations, ‘Do not stand by, thinking that somehow, because of what we’ve done, that it’s taken care of. It’s not.’ Preventing the next eruption is an even more distant goal.

As of 1 October, a third of all Ebola cases ever documented were registered in September 2014. More than seven thousand cases have been recorded since March, more than half of them fatal. In epidemiological terms, the doubling times of the current Ebola outbreak are 15.7 days in Guinea, 23.6 days in Liberia and 30.2 days in Sierra Leone. The US Centers for Disease Control and Prevention suggested at the end of September that unless urgent action is taken, more than a million people could be infected in the next few months.

The worst is yet to come, especially when we take into account the social and economic impact of the epidemic, which has so far hit only a small number of patients (by contrast, the combined death toll of Aids, tuberculosis and malaria, the ‘big three’ infectious pathogens, was six million a year as recently as 2000). Trade and commerce in West Africa have already been gravely affected. And Ebola has reached the heart of the Liberian government, which is led by the first woman to win a presidential election in an African democracy. There were rumours that President Ellen Johnson Sirleaf was not attending the UN meeting because she was busy dealing with the crisis, or because she faced political instability at home. But we knew that one of her staff had fallen ill with Ebola. A few days ago, we heard that another of our Liberian hosts, a senior health official, had placed herself in 21-day quarantine. Although she is without symptoms, her chief aide died of Ebola on 25 September. Such developments, along with the rapid pace and often spectacular features of the illness, have led to a level of fear and stigma which seems even greater than that normally caused by pandemic disease.