Monday 5 January 2015

Ebola 2015


2015 is intended to be the year in which the Ebola outbreak is overcome. Although getting precise figures in West Africa is hard, there are grounds for some optimism. Some West African countries have done very well, and others, such as Sierra Leone and Liberia, far less well. The estimates for the number of projected infections for 2015 vary so greatly as to not be helpful. Too much uncertainty, too many assumptions, mostly about human behaviour. West Africans have worked out that funeral practices have to change, and by now they may all have come to understand that Ebola actually exists, but in countries with poor documentation and weak infrastructures all these assumptions are questionable. To confuse matters, the WHO website seems to have fallen into the hands of journalists. It is full of uplifting personal stories, and the epidemiology is now harder to find, but here are their latest estimates: A total of 20 206 confirmed, probable, and suspected cases of Ebola have been reported in four affected countries (Guinea, Liberia, Mali and Sierra Leone) and four previously affected countries (Nigeria, Senegal, Spain and the United States of America) in the seven days to 28 December (week 52). There have been 7905 reported deaths.

Ebola is said to be hard to catch and easily prevented by simple precautions. Nonetheless, many African health workers have caught Ebola. This might be due to poor or non-existent equipment, poor training, fatigue, or simply an inability or unwillingness to follow strict protocols.

The call for Western nurses to go to Africa pre-supposes that they are better than African nurses. Colonialism is accepted in this instance. Otherwise it would be better to simply send African nurses rubber gloves and disinfectants and let them get on with it.  I do not know if Westerners are better nurses, particularly when carrying out fairly simple procedures. They may be, but quite a few of them have caught Ebola, and several have been flown back to their home countries, bringing the virus with them.

So we have a mystery. What is the game plan? Are Western countries motivated by some perverse sense of fair play, namely that the virus should be given equal opportunity to infect people in distant lands? Are the national authorities trying to show how good their own facilities and tracking systems are?  In point of fact they have often been shown to be haphazard, which is not surprising given the (current) rarity of the condition outside Africa.

Perhaps the authorities have done a cool calculation. They doubt Sierra Leone and Liberia will ever manage to control the outbreak. By providing equipment and health staff they hope to reduce the total number of carriers. (This assumes that carriers will always have free access to international travel, and will get through all controls, even a blanket quarantine). Treating a number of infected returning Western nurses at very high cost is a price worth paying, so this point of view asserts, because nurses will probably confess to being ill a bit sooner than African citizens fleeing the epidemic, and the cost of treating Western nurses is counterbalanced by their much better nursing skills, which reduces the case load at a global level. If all this is true, then it seems that nursing Ebola patients is in fact very complicated, and African nurses cannot or will not do it properly. This is strange, because there are many African nurses in the UK health service. I suppose it is possible that all the good ones have come to work in the NHS leaving West Africa denuded, or more likely that several West African countries did not bother too much about establishing good quality health services, but it seems an odd sort of globalisation.

Asking Western health volunteers to spend an extra week or two in a good hotel in Sierra Leone after completing nursing would probably catch most of the infections, and seems worth considering. The costs of the current policy of letting returning nurses come straight back home and then treat them if they become ill are hard to calculate since much of the system is up and running, but it is reported to be very high, and not negligible in a service under strain.

Quarantine would be far more effective, but that is too simple. Worse, it is unfashionable, and is often opposed on the basis that people would try to get round it. Some probably would, but some people get round all requirements, such as having to admit they been in contact with an Ebola patient and then felt ill.

In sum, the Ebola epidemic concedes that some African countries cannot provide their citizens with an effective health care system; that Western health workers are better at standard nursing; and that quarantine should not be used.  Now that a Scottish nurse with Ebola is in a critical condition in a London hospital the possibility of quarantine for returning health workers has been considered but turned down, on the grounds that it would lead to fewer such Western professionals being willing to travel to Africa to treat Ebola. However, the government's chief medical officer for England, Dame Sally Davies, has said the case raises questions about airport screening procedures. Whether these questions will lead to some answers seems unlikely. Returning doctors reported a chaotic environment at Heathrow airport, with everyone confined into a small room for testing, thus maximising the risk of cross infection among staff.

The UK authorities are now saying that the bodies of nurses who die of Ebola should be cremated immediately or, for those opposed to cremation, placed in sealed coffins. The charity which sent the nurse out to Freetown is carrying out an investigation and “will leave no stone unturned”.

2015 should be the year that Ebola comes under control, and there has been considerable progress in many areas,  but at the moment it is too soon to say that the situation has been contained.


  1. "the possibility of quarantine for returning health workers has been considered but turned down, on the grounds that it would lead to fewer such Western professionals being willing to travel to Africa to treat Ebola."

    For those motivated by the opportunity for moral preening, the quarantine might be attractive since it will add to the proof of their moral superiority. But what proportion are so motivated? Dunno.

  2. I suspect it is not the quality of nursing but the general conditions of sanitation and access to adequate medical care of any kind that accounts for the persistence of Ebola in parts of Africa.

  3. Nice of them to go and help, must cause a warm glow.

    Wonder if it was the scheduled end of her tour of duty or........