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In this file photo taken on Monday, March 31, 2014, UNICEF health workers teach people about the Ebola virus and how to prevent infection, in Conakry, Guinea.

In March, UNICEF health workers teach people about the Ebola virus and how to prevent infection in Conakry, Guinea.

PHOTOGRAPH BY YOUSSOUF BAH, ASSOCIATED PRESS  

Dick Thompson

for National Geographic

Published July 2, 2014

As the largest Ebola outbreak in history continues unabated, health authorities from 11 West African countries and international agencies began a two-day crisis meeting today in Accra, Ghana, on how to combat the crisis. The World Health Organization (WHO) says "drastic action" is needed to stem the outbreak, which since March has grown to 759 confirmed cases in Guinea, Sierra Leone, and Liberia, including 467 deaths.

Given that surveillance and response measures have held this terrifying disease in check for the past decade, why has the situation gotten so far out of hand this time?

As with earlier outbreaks elsewhere in Africa, containment and treatment measures are often hampered by tradition, superstition, and poor public health infrastructure. But this epidemic is especially pernicious for several reasons.

In the early stages of the epidemic, when it could have been more easily contained, few health professionals in the region even knew it was taking place. Though outbreaks are common in central Africa, the disease had almost never been seen before in western Africa. And many of the first patients did not have symptoms consistent with a hemorrhagic fever, which initially obscured its identification. The public health response was therefore slow, and officials who made statements were often trying to calm people's fears, giving inaccurate and sometimes contradictory information.

Unusual in Ebola outbreaks, the disease is spreading to urban areas, making it even more difficult to control. Two capital cities, Conakry and Monrovia, are already affected, and a third, Freetown, is at risk. (See "Q&A: What's Behind Worst-Ever Ebola Outbreak in West Africa?")

Ebola spreads to West Africa

The deadly Ebola virus has been leaving its mark on Africa since the first outbreak in 1976 in the Democratic Republic of the Congo. Since the World Health Organization began reporting Ebola cases in March 2014, 759 cases and 467 deaths have been recorded in Guinea, Sierra Leone, and Liberia.
Map of West Africa showing spread of Ebola cases and deaths.
Note: Suspected, probable, and confirmed cases. Deaths mapped in Sierra Leone are confirmed cases only. Map data from June 24, 2014; cumulative cases and deaths from July 1, 2014.
MAGGIE SMITH, NG STAFF; JOEY FENING. SOURCE: WORLD HEALTH ORGANIZATION

The First Cases

The first official notice of clusters of an unknown, highly fatal disease apparently arrived at Guinea's Ministry of Health on March 10. But experts believe the first Ebola cases began appearing at hospitals in Guéckédou, a city in the forested highlands of southern Guinea, at least as far back as December 2013 and possibly even earlier.

The ministry sent a team to Guéckédou to investigate on March 14. Not until a week later did they notify WHO of  "a rapidly evolving outbreak of Ebola virus in forested areas" in southeastern Guinea. By then there were 49 cases, including 29 deaths. A week after WHO's March 22 public alert, the numbers had jumped to 112 confirmed and suspected cases of Ebola virus and 70 deaths.

Patients were coming in without dramatic visible bleeding, instead presenting less unusual symptoms, including fever, vomiting, and severe diarrhea. (That's why responders in this outbreak are referring to "Ebola virus disease" rather than "Ebola hemorrhagic fever.") Even without the hemorrhaging, though, the case fatality rate is high, between 71 and 86 percent, and the virus spreads just as easily through contact with any fluid from the victim.

A picture taken on June 28, 2014 shows members of Doctors Without Borders (MSF) putting on protective gear at the isolation ward of the Donka Hospital in Conakry, where people infected with the Ebola virus are being treated.
Doctors Without Borders workers put on protective gear at the isolation ward of the Donka Hospital in Conakry, where people infected with Ebola are being treated.
PHOTOGRAPH BY CELLOU BINANI/AFP/GETTY IMAGES

Now cases have been identified in more than 60 locations in Guinea, Sierra Leone, and Liberia, threatening large cities as well as the countryside. Even for seasoned Ebola responders, this situation of multiple outbreaks across a vast area and into large cities is unique. Médecins Sans Frontières or Doctors Without Borders (MSF) has said that due to the scope and number of victims in this outbreak, it has reached its capacity to help.

In earlier Ebola outbreaks, such as in Sudan in 2004 and Uganda in 2012, the first response was to move suspected Ebola patients to an isolation facility. There doctors and nurses wearing full-body protective gear provided treatment. At the same time, other responders went into the community to begin the detective work of tracing the patient's contacts who might have been exposed to the virus. Eventually, as sources of infection were identified and removed from a vulnerable population, the outbreak would burn out. This approach has worked time and again in some of the most remote parts of Africa. But to be effective, responders need an early start, which they did not get.

The challenge now is twofold: to continue treating patients and to bring the outbreak under control. Treatment is dangerous for medical staff, and when they're sealed head to toe in protective gear with temperatures soaring above 90 degrees, it's also physically grueling. The work is also emotionally draining, as most of the young and old alike die despite heroic efforts. All this means that providing treatment to Ebola patients requires enormous physical and emotional stamina as well as courage.

Deep Distrust

Controlling the outbreak is no less daunting. "Educating populations is the best way to prevent transmission in the community," says David L. Heymann, a professor of infectious disease epidemiology at the London School of Hygiene & Tropical Medicine, who has responded to several Ebola outbreaks in the past, including the first outbreak in Zaire (now the Democratic Republic of the Congo) in 1976.

But such efforts now face a slew of difficulties. The work of informing at-risk populations is being thwarted by superstition, fear, and suspicion.

The first step in containment is to get those affected to health centers where they can be isolated and treated. But as community members are taken to isolation wards—most never to be seen again—rumors often circulate that the wards are not for treatment but for something more sinister.

So Ebola patients often hide from the authorities trying to gather names of close contacts. Those who are put in isolation may escape and be hidden by families. Sierra Leone has now made it a crime to hide victims, but punitive measures rarely make the job easier for public health responders.

A picture taken on June 28, 2014 shows tents in the isolation ward of the Donka Hospital in Conakry, where people infected with the Ebola virus are being treated.
Tents in the isolation ward of Conakry’s Donka Hospital. Ebola has killed more than 450 people in Guinea, Sierra Leone, and Liberia since March.
PHOTOGRAPH BY CELLOU BINANI/AFP/GETTY IMAGES

In places where the concept of infectious diseases is unknown, Ebola victims and their families are often stigmatized. Some in the community believe that the illness is the result of a curse and that those associating with the victim or the victim's family will fall under the curse as well.

Community life is disrupted when health workers suddenly appear, dressed in what appear to be space suits. And these communities often already have a deep-seated suspicion of outsiders. In this outbreak, health workers have been met with hostility and violence in several locations, and an MSF official said one team has had to withdraw from an outbreak site because of the intense local reaction.

Enlisting the Community

The people at greatest risk in Ebola outbreak areas have to accept that certain traditional activities, such as eating animals found dead in the forest, or bush meat, can be dangerous and should be abandoned. And they have to be persuaded to give up some of their longstanding burial practices, such as washing the body, since the Ebola virus can live on the skin of a victim even after death.

These public health messages are now being broadcast on television and radio in the region, but it's not yet clear whether they're changing behaviors. Trust in pronouncements by government or health authorities still appears to be low. In part, this may be due to comments made by public officials, such as the declaration in April by the president of Guinea that the outbreak was under control. Public trust suffered another setback in early May, when sites were reporting that the number of cases had dropped, in some places to zero. It quickly became clear that the outbreak was not over.

Members of the Guinean Red Cross walk during an awareness campaign on the Ebola virus on April 11, 2014 in Conakry.
Members of the Guinean Red Cross take part in an Ebola awareness campaign in April in Conakry. The outbreak may have begun in Guinea in December 2013 or perhaps even earlier.
PHOTOGRAPH BY CELLOU BINANI/AFP/GETTY IMAGES

Ebola responders report that local communities are still very frightened and view health facilities with suspicion. Though organizations are working to raise awareness, MSF says civil, political, and religious authorities are "failing to acknowledge the scale of the epidemic, with few prominent figures spreading messages promoting the fight against the disease."

WHO's meeting this week should raise awareness of the disease in the region, but that awareness has to be followed by widespread, accurate health campaigns, which will require a strong commitment from national leaders. Awareness campaigns can be effective if the community trusts the educator. This means framing the public health message in a way that addresses the cultural context of the audience. Public health educators must be active listeners—one reason anthropologists have long been essential members of outbreak-response teams.

The goal is to enlist the community in fighting the outbreak. It's possible to gain a community's trust and cooperation even in the midst of the frenzy of an outbreak. In some remote corners of central Africa, communities understand Ebola so well that they've learned to serve as their own surveillance system. But this is a long-term goal, and it will not be accomplished easily or quickly.

Dick Thompson was a communications official at WHO from 2001 to 2009. He specialized in outbreak communications and named the disease SARS. Prior to joining WHO, he was a science and medical journalist and bureau chief for Time magazine for 23 years. He now lives in Portland, Oregon.

10 comments
Anyanwumere Alagor
Anyanwumere Alagor

Time has come for governments at the local, state, and federal levels to wake up and deal with the reality of governing. Ebola epidemic in some parts of Africa is a wake up call as to where we are in terms of preparedness. According to this article, of the 759 people affected, 467 have died of the disease. That is, a virulence of 62%. Superstition, tradition, and poor healthcare infrastructure were cited as reason for the spread. While the outbreak of the disease was noticed, health officials were not made aware of it on time due to lack of system in place. As governments invest in terrorism, it should also invest in healthcare, especially, epidemiology surveillance of diseases and education of the people about the symptoms of the disease and actions to take to contain it from spreading to others when a victim is identified.

Paul Maher
Paul Maher

$5.00 of IV vitamin C, 20-40 grams IV QD would likely cure most of these patients in a week, research Fred Klenner, MD, Thomas Levy MD JD.

Egon Krebs
Egon Krebs

shouldn't we be distributing all drugs currently being tested for efficacy against this horribly dangerous disease?


who cares a bout possible side effects when the mort rate is over 60%?


and also, this would give those drugs expidited real world testing.


this should already be being done.


ALSO, has the CDC evaluated  surge production of any of these drugs, just in case it gets way out of hand in the coming months? which is probably going to do.

kelly lane
kelly lane

@Anyanwumere Alagor

Your comments were well said and I completely agree. This virus has been on the WHO and CDC radiar for several decades now, and this outbreak shouldn't have been a surprise, they knew this would happen. Virus's mutate and this one has done what they feared and now can last long enough to be spread. This is a horrid virus that kills in days and those poor people suffer. I hope the governments in control of that region listen, stop worrying about power, and start taking care of their people and their beautiful culture. What a horrible thing to happen.


Thank you for your post,

K. Lane

BJ DH
BJ DH

@Paul Maher please stop talking nutraceuticals when this is such a serious matter, people are dying, oranges don't cure ebola. The main prevention rests with sanitation and bush meat, please don't lead anyone astray, even if you mean well...

Rhett Dudley
Rhett Dudley

@Paul Maher not true vitamin c doesnt cure anything it doesnt affect immune system. Thats a fairy tale

Juanita de Jager
Juanita de Jager

Any preventative medication that can be used to enhance immune system for people not yet infected?

Thomas Willis
Thomas Willis

Not large enough outbreak for a test run you would have to shoot blindly.. you need at least 1000 people to test it's usefullness. Or effectiveness also there could be deadly side affects which with to small a group might go unnoticed

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