Rebuilding trust key to fighting Ebola in Africa

In the video, a man who has escaped an Ebola virus treatment center runs through the streets of Monrovia, Liberia, while an angry mob taunts the white physician who has come to calm the crowd and retrieve the patient. Workers dressed in green protective garb ultimately catch up with the patient, who is likely infectious, and force him into the back of a van, his legs flailing.

The dramatic video, filmed by CNN, demonstrates the widespread mistrust of the authorities in politically unstable areas of West Africa — one of the key factors that has led to the exponential spread of the Ebola virus there, Paul Wise, MD, MPH, a Stanford professor of pediatrics and a health policy expert, said during a panel discussion on the epidemic Sept. 23.

Wise noted that in many of the affected areas, military and government officials have victimized communities for decades. Locals have protected themselves by avoiding involvement with the state.

“Control of Ebola will ultimately require political legitimacy, at least in the health sector. That’s what happened in Nigeria [where the epidemic appears contained], even with its corrupt government,” Wise told an overflow crowd of some 250 people in the Bechtel Conference Center at Stanford. “You have to create treatment centers that are of the highest quality and that treat people with dignity — so people will want to go there, rather than escape.”

Grim forecast

Wise was among six panelists who addressed the myriad aspects of the epidemic, which Margaret Chan, MD, director general of the World Health Organization, has called “the greatest peacetime challenge” the organization has ever faced. The panel was sponsored by the Freeman Spogli Institute for International Studies and by Stanford Medicine.

Officially, more than 5,800 Ebola cases and 2,800 deaths from the disease have been reported in four countries: Liberia, Guinea, Sierra Leone and Nigeria. But panelists said those figures were vastly underestimated. At the current rate of spread, in which the number of new infections is doubling every three weeks, the U.S. Centers for Disease Control and Prevention estimates that 1.4 million people could be infected by the end of January 2015 in the absence of dramatic interventions, said Douglas Owens, MD, a professor of medicine and director of the Center for Health Policy at FSI.

But even with “very aggressive” intervention, Owens said, it’s estimated there would be at least 25,000 cases by late December. If intervention is delayed by just one month, there will be 3,000 new cases every day; if it’s delayed by two months, there will be 10,000 new cases daily, he said. “It gives you a sense of the extraordinary urgency in terms of time,” Owens told the audience.

You have to create treatment centers that are of the highest quality and that treat people with dignity — so people will want to go there, rather than escape.

While the United States and other countries, as well as international organizations, are committing manpower and resources to fight the epidemic, the panelists emphasized the importance of building local health systems decimated by years of neglect. In Liberia, for instance, there are 92 doctors in a country of some 4 million people, said Michele Barry, MD, a professor of medicine and director of the Stanford Center for Innovation in Global Health. The country’s only trained internist died of Ebola, as did the chief medical officer of the main hospital in Monrovia — both local leaders of the Yale/Stanford Johnson & Johnson Scholars program, in which physicians volunteer to respond to local health needs. “So it’s a tattered system,” she said.

Role of community workers

Tara Perti, MD, a CDC epidemic intelligence service officer who worked this summer in both Guinea and Sierra Leone, said she spent time at a treatment center in Kenema, Sierra Leone, later returning to find that no one was there to help. “I received the terrible news that there were no physicians caring for approximately 90 patients at the treatment center,” she said.

She said mobilizing trusted community workers will be key to containing the epidemic. In Guinea, she traveled to a village north of the capital city of Conakry, where she met two young men who had recovered from the disease, which has a fatality rate as high as 70 percent. One of the men had lost five members of his family, but he had become a community advocate. He traveled with Perti to a neighboring village, where they met a woman who was sick and whose son had died of the disease. “She was very fearful of going to the treatment center … but she was ultimately convinced to seek treatment. She recovered and was able to return home,” Perti said.

“The patient who survived was tremendously helpful because he could speak from experience and be credible. There needs to be more of these. In the forested region of Guinea, there are a lot of superstitions and different beliefs besides germ theory, and so it’s very challenging to go into those areas and help people understand that Ebola is a virus, it’s real and we do have ways to help patients.”

Even in the absence of sophisticated drugs, which are exceedingly scarce and untested in humans, simple methods of supportive care can be essential to survival, she noted. “Although there isn’t targeted therapy, IV fluids are very helpful,” Perti said. “Many people die of shock, so it’s important to maintain blood pressure. Many have malaria, as well, and receive treatment. It’s important to get the message out that you have better odds of survival if you can get to a treatment center.”

Barry also advocated for the creation of a global health resource corps, a reservist group of physicians and nurses available to respond to major disease outbreaks like Ebola. While she lauded the enormous effort of private groups like Doctors Without Borders and Partners in Health, which have played a major role in battling the disease, their work has not been effectively coordinated on the ground.

“This has all been done in a disjointed, uncoordinated way,” Barry said. “It would be great to have a central global health strengthening fund, with a reserve of nurses and physicians who could sign up.”