Monday, August 25, 2014

Why Are We Waiting For Ebola?

A version of this article was previously published in The Star.

One thing’s for sure. Ebola is not a particularly easy disease to catch. Derek Gatherer, a virologist at Britain’s University of Lancaster, was recently told Reuters that the virus is not "super-infectious”. In fact it is much less easily passed on than measles. You do not get it just by being in the same room with, or on the seat next to, someone who is infected. It is spread through direct contact with the bodily fluids of an infectious person. However, by the time they are infectious, victims are typically very ill, many with scary symptoms like bleeding through the eyes and ears. In short, you can spot them from a mile off and take precautions. So why is it killing so many people in West Africa and why is it scaring Kenyans, who are on the other side of the continent?

According to the book Compassion Fatigue: How the Media Sell Disease, Famine, War and Death by Susan D. Moeller, “the chief means of transmission in its major outbreaks have been either surgery and routine lab works performed under conditions of primitive hygiene or close contact with desperately ill patients or the dead.” The virus preys on dangerous superstitions and unsanitary customary practices in the handling of dead bodies as well as unsanitary conditions and practices in medical facilities. Sad to say, both of these are not exactly unheard of on our continent.

The majority of those who get infected either do not know enough about the disease to protect themselves, or should know better and somehow don’t. It is ignorant (and I do not mean this in a disparaging sense) villagers and negligent medics who seem to bear the brunt of the disease. Ebola exploits the chronic weaknesses in economies and healthcare systems across the continent and the government policies that perpetuate them.

According to a paper by Adam MacNeil and Pierre E. Rollin, outbreaks of Ebola (and its deadly cousin, the Marburg virus) “are components of impoverished conditions.” They note that outbreaks commonly occur in rural and highly remote areas of central Africa which house some of the least developed locations in the world. They cite the fact that more than two thirds of the population in Gulu, Uganda, the site of the 2000 Ebola outbreak, live more than 5 km away from the nearest health facility.

Today, the most affected countries, Liberia and Sierra Leone, have had their healthcare systems decimated by decades of looting and civil conflict. Fourteen years of intermittent civil war destroyed much of Liberia’s public health infrastructure and despite recent improvements, one of the country's health administrators says “these are still too fragile, and don't have the capacity to deal with an outbreak of a problem like Ebola."

This weakness manifests itself in the high number of infections among healthcare workers. According to WHO, this number has reached 170 with at least 81 deaths. The lack of supplies, including basics such as gloves, as well as lack of knowledge or experience in using protective equipment is to blame for many of the infections. And this is down to a lack of government investment in health. At 16.8 per cent, the Liberian government’s contribution to total health expenditures is one of the lowest in the world.

What does this have to do with Kenya? Well the Kenya Service Availability and Readiness Assessment Mapping is the first Health Services Census to be conducted in Kenya and provides, according to Dr Francis Kimani, the Director of Medical Services, "the most comprehensive picture of the Health Sector in Kenya to date." One might add that its findings make for some depressing reading.

Generally, it says, less than 6 in 10 of all health facilities in the country are ready to provide the Kenya Essential Package for Health –a sort of standardized comprehensive package of health services. Less than half have the basic amenities to provide services. And while two-thirds have half the basic equipment required, 59% do not have essential medicines. Only 2% of facilities are providing all KEPH services required to eliminate communicable diseases.

Further, more than a third of all hospitals in the country do not have safe procedures for disposing of sharps (injections, razors and needles) or even infectious waste. A similar number did not have proper storage facilities for sharps or infectious waste, lacked soap and water and do not have written guidelines on standard precautions as required.

The Standard cites a study carried out last year by the ministry and the Kenya Medical Research Institute at the Level Five Rift Valley Provincial Hospital in Nakuru which showed that health workers carelessly expose themselves to unnecessary injuries and contaminated fluids in hospitals, and claims 51 per cent of medical staff are untrained on the proper use of sharp hospital equipment. So though the government might be investing in “some 5,000 special personal protective gear,” as Armand Sprecher, the medical adviser to Doctors Without Borders for hemorrhagic fever, says, even full protective gear might be useless if “you stick yourself with a needle.”

The fact is the rush to train up our medical staff now in what should be the basics reveals the rot at the core of the system. When medical staff go unpaid for months, as they recently did, we have to ask what this tells us, not only about the potential problems with our new governance arrangements, but how these are impacting the availability of healthcare to the population (several people have died as a result of the go-slow that followed).

While there may be no cure for Ebola, many experts say early and intense medical care can greatly improve a person's chances of survival. According to Dr Lee Norman, the fact that the disease’s mortality is much higher in remote areas “reflects the fact that if more care is given and care is given early, the more survival improves." Therefore, prior investment in properly equipped hospitals, good doctors and working systems would not only prevent the spread of the disease, but even keep those infected alive.

Take the example of Michelle Barnes. After contracting the Ebola-like Marburg virus during a trip to Uganda in 2007, she travelled back to the US where she fell ill. Though without a diagnosis for what was ailing her, she was treated, in her words, by “more than 220 health care professionals ... over 12 days” after which she was able to go home. Though she had interacted with many people on her flight back to the US as well as before she was admitted to hospital, none of them got sick. She attributes this to the fact that people in the US “have access to more sophisticated health infrastructure, better information about the spread of disease, and practices that more effectively contain infections.”

In Nigeria, Lagos state Governor Babatunde Fashola also emphasized the importance of good basic care in preserving the lives of Ebola patients. "This is a virus that will run a maximum of 21 days. What we must do is people who show some signs of illness should come in very early so that we can continue to hydrate them, give electrolyte balance so that their nervous system do not go into shock and wherever it is necessary to provide antibiotics for patients; and their body can fight the virus which in the event last no longer than 21 days."

Again, it seems to come down to education and investment in basic medical infrastructure. Uganda, which has suffered several Ebola outbreaks since the turn of the century, has recorded success in tackling them using public education campaigns as well as developing an efficient system for faster medical response. It has invested in educating both healthcare workers and the general public on Ebola, even creating an SMS-based health monitoring system known as mTrac that helped with the last Ebola outbreak (our own Silicon Savannah types might want to take notice).

However, Dr Wadembere Ibrahim Jangu of Makerere University, School Of Public Health, in 2012 called for sustained investment in community education as well as equipping health centers with supplies and basics like hand washing facilities, as well as monitoring their waste management and infection control measures.

“Why wait for an outbreak in order to do everything right?” he asked. Kenya, too, would do well not to wait for Ebola in order to fix its health system.