An expert's point of view on a current event.

Don’t Kiss the Cadaver

Since 1976, Africa has reported over 2,000 cases of Ebola. Lessons were learned -- it's now up to Guinea to remember them.

Laurie Garrett
By , a columnist at Foreign Policy and former senior fellow for global health at the Council on Foreign Relations.

Despite millions of dollars in research on vaccines and treatments, the deadly and frightening Ebola virus is best tackled today the same way it was during its first epidemic in 1976: With soap, clean water, protective gear, and quarantine. In fact, the care, treatment, and control of the virus is most effective when handled the way American physicians dealt with the 1918 influenza pandemic almost 100 years ago.

Despite millions of dollars in research on vaccines and treatments, the deadly and frightening Ebola virus is best tackled today the same way it was during its first epidemic in 1976: With soap, clean water, protective gear, and quarantine. In fact, the care, treatment, and control of the virus is most effective when handled the way American physicians dealt with the 1918 influenza pandemic almost 100 years ago.

The outbreak now unfolding in Guinea — the first in West Africa in 20 years — has also spilled over into neighboring Liberia and possibly Sierra Leone. With 122 cases and 78 deaths reported to date, the epidemic has officially been declared a “regional threat.”* The West African region shares a vast tropical rain forest rife with virus-harboring animals, including rodents, bats, and chimpanzees.

The Ebola hemorrhagic disease is terrifying, as the virus punches microscopic holes in the endothelial lining of blood veins, vessels, and capillaries, causing blood to leak from its normal pipelines coursing through the body. Within hours, the punctures enlarge, the leaking turns into a flood, and blood pours into the intestines, bowels, and respiratory channels. As the victims become feverish — raging in pain and hallucinations — their tears drip red with blood. The crimson liquid flows from their noses, ears, bowels, bladders, mouths, while old wounds reopen all over their bodies. The deterioration is swift, transpiring from infection to death typically within five days. And Ebola is spread, via the infected body fluids, to attendant family members, health-care workers, and funeral preparers.

In 1995, when I was reporting on the Ebola epidemic in Kikwit, Zaire (now the Democratic Republic of the Congo), the disease struck terror across the community of some 600,000 people, many of whom would wail through the pitch dark night the names of the virus’s victims. The dread was compounded by the inability of doctors and nurses in the region’s clinics to protect themselves. As medical workers contracted the infection and fled their posts or succumbed to Ebola, the Kikwit community wondered, “What dreaded thing is this, that even the doctors cannot protect themselves?”

When all was said and done, there were 160 confirmed or suspected cases of the virus and 121 deaths throughout the country — Kikwit was home to 138 of these people.

Thanks to the bravery and sound scientific work of the international response teams that responded to the original 1976 epidemic in Yambuku, Zaire, and the subsequent outbreak in Kikwit, the governments of Guinea, Liberia, and Sierra Leone can today make smart decisions to stop the virus from spreading and save lives. African communities no longer need to live in horror and dread, fearful of the lurking virus. Nor must they depend on nonexistent miracle drugs and vaccines from the outside wealthier world.

* * *

On behalf of the World Health Organization in 1976, Karl Johnson, a trout-fishing epidemiologist from the American Rockies, led a hastily assembled international team of African, European, and American scientists to respond to what was then a completely mysterious epidemic unfolding in one of the most remote locations in the world. The brutal Mobutu Sese Seko regime that then ruled Zaire spent nary a franc on the far-flung rural villages of what was once the Belgian Congo, built no roads or airports, and gave only lip service to the country’s own medical and public health infrastructure. Johnson’s team of disease cowboys was largely on its own to find means of transport, to discover the epidemic’s cause, and to figure out how to stop it. Worse, it was rumored that another outbreak of the same mysterious microbe was unfolding to Zaire’s north, in an even more remote southern corner of Sudan.

As I described in detail in my first book, The Coming Plague, Karl Johnson’s 1976 team had no technological tools at their disposal — vaccines, cures, genetic screening, or rapid diagnostics. One team member, American Joe McCormick, was dispatched with an old Land Rover, some food, and water to drive all the way from Zaire’s capital city of Kinshasa to southern Sudan, guided by little more than old Belgian maps and a compass. His “roads” proved to be nothing but Congo river rafts and footpaths, which formed a commerce network of trade between villagers who spoke no English, very little French, and divergent Bantu dialects.

Johnson deployed a Belgian medical duo — one of which was the now-famous Peter Piot — to the Zairois village of Yambuku, thought to be the epicenter of the mysterious outbreak. The Belgians discovered that the entire epidemic was spawned by a Catholic missionary outpost so poorly supplied that it reused the same five hypodermic syringes for everything from vaccines to anesthetics, unwittingly spreading the Ebola virus with each injection.

Up in Nzara, Sudan, McCormick found that humans there were also responsible for spreading the virus, as families washed the bodies of their loved ones and swathed them for burial, infecting themselves with virus-laden blood in the process.

In my second book, Betrayal of Trust, I detailed my observations of the 1995 Kikwit epidemic. Though nearly 20 years had passed since Karl Johnson’s intrepid team faced Ebola in Yambuku and Nzara, the tool kit was little improved: There was still no vaccine, treatment, cure, diagnostic, or knowledge of where the virus came from.

Once again an international scientific and medical team was assembled, led by the World Health Organization’s American-born David Heymann. The Dutch chapter of Médecins Sans Frontières (MSF) deployed a tiny team to help in Kikwit’s largest hospital; Zimbabwe and South Africa sent animal experts to detect the source of the mysterious virus; and local Zairois scientists and medical students spread out across the town in search of clues to the epidemic’s origin and solution.

* * *

Since 1976, some 2,200 cases of Ebola have been confirmed in outbreaks spread across equatorial Africa, from its far west to Gulu, Uganda, in the east. Of those, 1,500 were fatal, with mortality rates as high as 95 percent during the Yambuku and Kikwit epidemics, and as low as 35 percent in the more recent outbreaks in Uganda, Sudan, and Congo.

It is not clear whether the decline in fatality is due to waning virulence in the virus or other factors: Combined cases from 1976 to the present have had a 60 percent mortality rate, making Ebola a highly lethal virus for human beings.

From the Yambuku, Nzara, and Kikwit epidemics, researchers have learned at least seven lessons that can effectively guide responders today in Guinea and its neighboring countries.

First, the index case — the initial person contaminated with the Ebola virus — is usually a hunter or villager who recently spent time deep in a tropical forest and came into contact with an animal carrying the virus. In Yambuku, the index case was a hunter; in Kikwit he was a charcoal-maker who spent a week burning wood in the forest to sell in town; in a prior West African outbreak, the index case was a family that killed and ate an ailing chimpanzee. Stopping the spread must include cutting off contact between forest animals and human beings, especially tropical fruit bats that harbor the virus without harm to themselves, and the monkeys and apes that eat the bats or the fruit that they chew on, contracting Ebola in the process.

A broad range of mammals can be infected lethally with Ebola experimentally, demonstrating that the probable bat-host species can pass the virus to dozens of intermediary species, from which humans get infected. There is some evidence that the virus mutates inside monkeys and apes, adapting to become more infectious to primates, including human beings. Guinea’s government has wisely issued warnings to its populace: Do not eat bats or monkeys. Moreover, it has banned the trade in wild animal flesh, or so-called “bushmeat” — measures neighboring Sierra Leone and Liberia would do well to immediately imitate.

The past epidemics indicate that outbreaks in humans are preceded by deaths among forest animals, especially primates, and may be spawned by stress on the bat populations. Across Africa, typically shy bat species pollinate the trees of the rain forests as they nocturnally scour for fruit. As the heat increases in the upper canopies of forests, due to climate change, and as humans increase their logging operations, the bat populations are now under great stress.

When distressed by such environmental changes, animals are more likely to venture near human habitation in search of food and come down from the upper tiers of forests into tree levels filled with predatory monkeys and chimps.

Once in Nzara, McCormick found the rafters of a Sudanese textile warehouse filled with bats. South African virologist Robert Swanepoel found swarms of bats in trees inside Kikwit town, and traces of Ebola in their blood. Even bats found in a cave in Spain carried Ebola. The bats play a vital role in the survival of rain forests: The solution is not elimination of the animals, but of human contact with them.

Third, the bravest interventions, and most essential, are those carried at great personal peril by local Red Cross volunteers. Stopping an Ebola epidemic requires removing ailing individuals from their homes and placing them in isolation quarantine.

Families protest: Who wouldn’t? Taking parents from their children, wives from their husbands, babies from their mothers’ breasts are all acts that evoke rage and sorrow. But leaving the bleeding patient in the home, to spread the virus to family members, guarantees the epidemic will persist.

In Kikwit, it was obvious that foreigners drew greater outrage than local volunteers, though even Kikwit’s brave Red Cross members were sometimes beaten and, sadly, infected as they carried out their sorry duties. The International Red Cross sent teams into Guinea this week — a measure the organization failed to undertake in the Zaire epidemics. It is essential that local Red Cross volunteers receive full international support, protective gear, and sophisticated training wherever Ebola surfaces.

Fourth, burials must — despite religious and cultural preferences to the contrary — be carried out without ceremony, with bodies placed in deep-dug graves to avoid spread within funerals. Traditional practices of touching or kissing the cadaver in open-casket ceremonies must be prohibited.

Fifth, though it is rare, the Ebola virus can be spread through the air between people. Every health worker, Red Cross volunteer, gravedigger, and outbreak investigator must wear protective face masks when near an infected animal or individual. Such masks are not routinely available in rural Africa: Even Kinshasa had few in 1995. Among the most important supplies donated by outsiders are protective face masks.

Sixth, MSF now has much experience with Ebola, as teams of the Nobel Prize-winning organization’s medical and humanitarian response personnel have been engaged in nearly every Ebola outbreak since Kikwit.

I arrived in Kikwit within hours of the small MSF team led by Dutch physician Barbara Kerstiens and watched as they swiftly erected a rainwater catchment, electrical generators, and basic barrier protections for quarantine in and around the primary hospital. Before MSF arrived, Ebola spread like wildfire among doctors, nurses, lab techs, and orderlies — none of whom had soap, running water, electricity, latex gloves, masks, or protective gowns.

MSF is now on the ground in Guinea, no doubt bringing safe infection control to local hospitals. They need support — not in the form of exotic disease spacesuits and $300,000 mobile laboratories, but with supplies of soap, antiseptics, water filters, generators, and basic protective gear.

Seventh, forget about high-tech solutions, “cures,” and vaccines: They do not exist. Following 9/11 and the 2001 anthrax attacks, the U.S. Congress ordered the U.S. Centers for Disease Control and Prevention to designate a list of possible bioterrorist germs, and under Project BioShield it financed R&D on treatments and vaccines. Though Ebola was on that list, and in 2011 alone garnered $5.4 million in research funds, a list of exotic treatments for the disease, including monoclonal antibodies and genetic manipulation, have never left the lab bench.

Tests of Ugandan Ebola survivors show that their bodies make antibodies against the virus that persist in their bloodstreams for many years, but researchers have had little luck in concocting an Ebola vaccine or proven antisera. And private-sector vaccine developers see no commercial basis for Ebola products given the rarity of outbreaks and the impoverished status of those most likely to need immunization.

* * *

In early March, I had dinner in London with Peter Piot, who now runs the London School of Hygiene and Tropical Medicine. He had just returned from Yambuku. It was the first time he had been there since 1976, and he’d found the visit a shattering experience. The local Catholic hospital was even less equipped in 2014 than it had been in 1976, and the villagers live more desperate, impoverished lives today than they did 38 years ago. “It’s terrible, just terrible,” Piot repeatedly told me.

Three years after the 1995 Kikwit outbreak, I too returned to the strange site of the epidemic I had experienced, making similar, sorrowful discoveries. Mobutu died not long after the Ebola epidemic, leaving the national treasuries literally empty: He and his clan had looted every bar of gold and piece of foreign currency that once sat in vaults, supposedly guaranteeing the “validity” of Zaire’s currency. Civil war broke out, elements of which still smolder across the country in 2014.

To get to Kikwit in 1998 I had to buy a “seat” on a stolen military transport plane, strapping myself atop a large wooden crate inside the cargo hold. The Kikwit landing strip had been a groomed soccer field just three years prior. By the time I stepped off the plane, the grooming had ceased and the cargo plane bumped across tall weeds that were whacked by the plane’s propellers.

As I proceeded to the hospital — which had been full of dying Ebola patients in 1995 — I spotted the ambulance that the German government donated during the epidemic. It was transformed into the local governor’s private limousine.

At the hospital entry I spied a familiar sight — a large pit filled with burning logs, over which a steel tripod held a cauldron of boiling water used for sterilizing syringes and equipment. The generators MSF had brought to power sterilizing autoclaves? Long gone, looted by military thugs along with the X-ray machine, doorknobs, microscopes, toilets, and every other item thought to have a resale value.

Over bowls of rice, I had a farewell lunch with one of Kikwit’s surviving nurses — a young man who contracted Ebola on the job and was among the lucky 5 percent who outlived the damned microbe. He told me that every day was greeted with dread, as soap, water, gloves, and masks were no longer available.

As he spoke, he trembled with fear. I reached into my camera bag and pulled out two small bottles of Purell hand sanitizer. The nurse’s eyes popped, he snatched the bottles, and hid them in his pants. Scanning the dining room to see if any colleagues had spied the precious cleanser, the nurse feigned nonchalance and sauntered to his staff locker, hiding the Purell inside.

As I prepared to leave the Kikwit hospital, he walked up beside me, smiled, and whispered: “Tonight I will finally sleep.”

*Update, March 31, 2014: This article has been updated to reflect a more recent death toll and the confirmation of cases of Ebola in Liberia. (Return to reading.)

Laurie Garrett is a columnist at Foreign Policy, a former senior fellow for global health at the Council on Foreign Relations, and a Pulitzer Prize-winning science writer. Twitter: @Laurie_Garrett

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