Once again, Africa is in the international spotlight. As usual, the news isn't good.
The media seems to alternate between long stretches of ignoring Africa entirely, punctuated by short bursts of completely freaking out about the continent, usually due to a new outbreak of disease or terrorism that we fear may spread to our own shores. The recent Ebola outbreak in West Africa, which has infected almost 2,000 people over the past six months, is no exception.
Of course, we should care a great deal about the Ebola outbreak, but not for the reasons propagated by cable news and bloggers alike. We should care about Ebola not because of the threat it poses to us as Americans, but for what it says about the current state of the health care system in much of Africa and many other resource-limited settings around the globe.
Sadly, the media has instead coalesced around the following five myths, while ignoring the larger public health context and incredible health disparities present in our world.
Myth #1: Ebola is a universally fatal disease.
Ebola can certainly be fatal, but not universally so. In fact, the case fatality ratio for Ebola and its close cousin, Marburg virus, varies greatly depending on the setting. The first recorded outbreak of these diseases, which occurred in Germany and Yugoslavia in 1967, had a mortality rate of 23 percent - high by any standard, but far lower than the 53-88 percent mortality seen in subsequent outbreaks in sub-Saharan Africa over the next 40 years (1). (This first outbreak also occurred before anything was known about the disease and before the widespread availability of modern emergency departments and intensive care units in Europe.)
The risk of death for individuals infected with Ebola or Marburg in the United States or Europe today would almost certainly be far lower than that seen in any of the previous outbreaks. The two Americans recently infected in Liberia, for instance, are by all accounts improving, not because of any magic serum they received, but because of the close monitoring and care provided by their aid worker colleagues and their rapid evacuation to a modern hospital with intensive care facilities.
I have cared for patients and trained physicians in dozens of urban and rural hospitals across sub-Saharan Africa over the last decade. The mortality rate for nearly every disease I have ever managed, from pneumonia to heart attacks to cancer to motor vehicle accidents, is at least an order of magnitude higher in sub-Saharan Africa than for the exact same disease managed in an American hospital.
When it comes to your likelihood of dying from any disease in this world, Ebola included, geography matters.
Myth #2: There is no treatment for Ebola.
There are actually several effective treatments for Ebola that can help support individuals through the worst phases of the disease and increase their chance of survival. These treatments include early and careful resuscitation with intravenous fluids; blood products such as packed red blood cells, platelets, and concentrations of clotting factors to prevent bleeding; antibiotics to treat common bacterial co-infections; respiratory support with oxygen, or in severe cases, via a ventilator; and powerful vasoactive medications to counter the effects of shock. In addition, modern diagnostic equipment can help doctors and nurses continuously track vital signs in order to rapidly detect and manage new complications of the disease and stay one step ahead of the virus.
The incredible thing about these already proven treatments (as opposed to the experimental ones being discussed at length in the media) is that they can be used to fight not just Ebola but a myriad of other diseases across Africa. During the past six months that the Ebola outbreak has claimed the lives of nearly 1000 children and adults, approximately 298,000 children have died of severe pneumonia, 193,000 children have died of severe diarrhea, 288,000 children and adults have died of severe malaria, and 428,000 children and adults have died from injuries like car accidents, all in sub-Saharan Africa alone.
Better access to emergency and critical care services could help save patients with Ebola as well as those affected by these and many other far more common killers.
Myth #3: Ebola is the most contagious disease known and will spread rapidly across America if it is allowed to enter the country.
Ebola is not the most contagious disease known. It's not airborne and it's not even spread by aerosols (small droplets of spit that float through the air). This makes it less contagious than a host of other diseases, such as measles, chicken pox, tuberculosis, or even the seasonal flu. To the best of our knowledge, Ebola is spread only by close physical contact, especially with bodily fluids. So unless someone on the subway vomits, defecates, or bleeds on you (or rubs up against you very closely for a long period of time), they aren't going to be passing Ebola onto you.
In a medical setting, all that is required to prevent the spread of Ebola from patient to health care worker to patient is the use of "contact precautions," which include gowns, gloves and regular hand-washing after every patient contact -- precautions that are standard in the intensive care units of all U.S. hospitals where patients with Ebola would be treated.
Contrast that to West Africa, where Ebola has been spreading rapidly due to a lack of basic public health measures in poorly equipped government hospitals and clinics. Many health centers and hospitals lack adequate supplies as basic as gloves and gowns, and many also lack the running water or alcohol-based solutions required for health care professionals to cleanse their hands in between patients. Unlike the United States, hospitals in Africa tend to have open wards with dozens of beds crowded into a single room and, in many cases I've seen, multiple patients sharing a single bed. It's not hard to see how Ebola can spread quickly in these types of crowded situations.
The best way to help Africa stem the tide of the current Ebola epidemic is by rapidly investing in and deploying basic infectious control measures like gowns, gloves, water, and sterilization tools, coupled with health worker and community health trainings in how to properly use them.
Myth #4: We need to start giving experimental Ebola drugs right away to as many Africans as possible to help stem the outbreak.
Any human being given an experimental treatment that has not yet been proven safe and effective in humans is, by definition, being experimented upon. Now, experimenting on humans, even those in poor countries, is not necessarily a bad thing. In fact, conducting research in resource-limited settings is a big part of my own job. However, every person enrolled in a medical research study, whether they are American or African, is entitled to the same basic international ethical protections, and people in poor countries actually deserve special protections.
For instance, while studies in the United States require approval from just one ethical review board, most studies in low-income countries require approval from two separate ethical review boards -- one international and one local. In addition, consent forms, which spell out the risks and benefits for patients of a particular study, must be translated into all local dialects, and special provisions must be made for patients who cannot read the forms or sign their name. Finally, every patient enrolled in a study, whether they be in a treatment group or comparison group, must also receive the very best available proven treatments for the disease, which in the case of Ebola would include all of those outlined above. This would ensure that all patients in the study receive some benefit from the research, even if the experimental drugs turn out to be ineffective (or harmful).
Sadly, we have known about Marburg and Ebola viruses for almost 50 years now, and similar to so many other neglected tropical diseases, we have so far conducted pitifully little research into effective treatments or vaccines. This is not due to a lack of interest on the part of doctors and scientists, but rather a lack of money. Drug companies are generally not willing to invest in research to prevent or treat diseases that only affect poor people, since they are unlikely to ever turn a profit.
Americans could rectify this problem by pushing President Obama and Congress to reinstate the funds cut from the National Institutes of Health (NIH) as part of the sequester and urge the NIH to dedicate a larger portion of its funding towards research into diseases affecting the world's poorest citizens.
Myth #5: Nothing can be done to help Africa -- it's just too poor.
The true tragedy of the Ebola outbreak is that most Africans lack access to the very same medications, equipment, and skilled physicians and nurses that have been available in the United States and Europe for several decades, and that could have prevented the current epidemic from raging out of control. Moreover, these very same measures could also be used to reduce mortality from the variety of other diseases currently killing thousands of times as many Africans each day as Ebola.
These lifesaving treatments are not out of reach for the continent. At this very moment, through a partnership between USAID, the Global Fund, the Rwanda Ministry of Health, and a consortium of American universities, we are currently training a cadre of emergency medicine and critical care physicians and nurses in Rwanda, one of the poorest countries in Africa. At the same time, we are also rapidly scaling up the health care infrastructure and drug and equipment supply chains in Rwanda, so that these new African specialists have the tools they need to care for the continent's sickest patients. Even before the recent outbreak of Ebola there, a similar effort has been under consideration for Liberia, though it is still awaiting U.S. government approval.
Our experience in Rwanda is proving that with enough political will and outside financial and technical support, African countries can achieve large scale improvements in their capacity to both prevent disease and manage even the most critical and emergent conditions -- not overnight perhaps, but in time to prevent the next big epidemic before it even begins.
(1) Beer B, Kurth R, Bukreyev A. "Characteristics of Filoviridae: Marburg and Ebola Viruses." Naturwissenschaften 1999; 86, 8-17.
Adam Levine is an Assistant Professor of Emergency Medicine and Director of the Global Emergency Medicine Fellowship at Brown University. He currently serves as the Clinical Advisor for Emergency and Trauma Care for Partners In Health/Inshuti Mu Buzima and as a member of the Emergency Response Team for International Medical Corps. His research focuses on improving the delivery of acute care in low-income countries and during humanitarian emergencies. The views expressed in this blog are his alone and do not necessarily represent the views of any of the organizations mentioned above.
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