September 8, 2014

  Could Ebola Wipe Out West Africa?
Paul Conton

It could, if we don’t make the right decisions. It hasn’t happened in modern times, but in the Middle Ages, plagues regularly decimated whole nations. From one victim in a small corner of Kailahun, Ebola has invaded nearly every corner of Sierra Leone, taking hundreds if not thousands of victims in the process. There is no evidence that we are even close to halting Ebola’s advance. The rate of increase of confirmed cases is near-exponential. When the President announced the State of Emergency on July 30 this year, less than 540 cases had been confirmed. Today, five weeks later, we have 1,276 cases (Ministry of Health Sept 7 Situation Report), almost a 150% increase. Clearly, even if one argues the Emergency measures announced by the President prevented the situation getting even worse than it is today, they have not halted Ebola’s spread. Those first 540 cases occurred over a period of nine weeks from May 28 when the first cases in Sierra Leone were reported. In the six weeks since the President’s speech we have had an additional 746 cases. Far from Ebola retreating at the State of Emergency, it continued its attack with increased vigor. If we make no major adjustments at this point and if one assumes, optimistically, the same rate of increase as in the past weeks, rather than an exponential increase, by mid October we should have 2,000 cumulative cases. Assuming, again optimistically, a 50% Case Fatality Rate, these cases would have resulted in 1,000 deaths. And these are just laboratory confirmed cases, not including the many non-laboratory confirmed Ebola deaths that we know are taking place. After October, with the disease entrenched in every neighbourhood, who can tell how long it would take for Ebola to kill a majority of Sierra Leoneans?

We HAVE to change. We HAVE to try extreme measures to avert what is already a disaster and could soon be an apocalyptic catastrophe. Listening to the comments of the general public, one does not get the impression that there is a full realization of how difficult our situation is. The international community realizes this better than we do. The language from normally diplomatic international experts, the WHO, CDC, MSF etc, could not be more blunt. We are facing doom. And they don’t have the answers. If they did they would have provided them by now. There's a good reason that America and other technologically advanced nations have studied biological warfare for decades. They have long understood that certain biological agents, bacteria and viruses such as Ebola, could wipe out entire peoples far more effectively than bombs. Sierra Leoneans, perhaps more than most Africans, tend to rely on outsiders for help in a crisis. The West. Our Colonial mastters. America. In this case, Obama, the CDC and WHO are as scared and helpless as all the rest of us. The UN Coordinator on |Ebola, David Nabarro, has been giving a time frame of six to nine months for "MAYBE" containing Ebola. Realistically, at the present rate of spread, in that time tens of thousands will have died.

No one currently has the answer to West African Ebola. All we can do is intelligently try different things and carefully and quickly evaluate their effectiveness. Fortunately we have one clear yardstick for evaluation: the number of confirmed cases. If the numbers of new cases are going down we are succeeding (assuming cases are being recorded consistently). If they are going up, Ebola is winning.

My suggestions for the Ebola fight are these:

(1)    The proposed three-day stay at home has generated much controversy, with some opposing it. I think it is too little too late. An extreme situation, such as we have now, calls for an extreme response. If the incubation period is 21 days, then the stay at home period should be at least 21 days.  This should help greatly in reducing the transmission of Ebola. The stay at home could be mitigated somewhat by emergency distribution of food, or by a daily lifting of a curfew for a few hours to enable citizens to obtain food and other necessaries. This would have to be carefully managed to avoid panic and riot.

If for political reasons only a 3-day lock down is authorized, restrictions on changing one’s residence during the period of this emergency could be introduced, such that special permission would be required to set up residency in a new area.. Chiefdom law used to require strangers to report to the chief immediately upon arrival. Perhaps this is the time to reintroduce this law if it has lapsed and to extend it throughout Sierra Leone, including Freetown and other cities. Neighbourhoods should be on alert to report all new arrivals. Ebola spreads to new areas when Ebola patients travel from their place of residence, so this restriction should help to curb the spread of the disease.

(2)    We need isolation centers more than we need treatment centers. The two purposes are often intertwined, but they are actually quite distinct. Treatment can’t stop this epidemic, because, as of now, there is no effective treatment. Isolation, on the other hand, could stop this epidemic. If it were possible to effectively isolate all current Ebola patients the outbreak would be over in 21 days. Finished. Period. So what we can not currently do with treatment, we might be able to do with isolation.

The whole issue of the treatment of Ebola is problematic. Whichever way you look at it, whoever’s numbers you believe, the success rate of Ebola treatment is poor. And treatment of Ebola patients by medical workers carries with it the very serious risk of these medical workers themselves becoming infected and then going on to infect others in their institutions and their families and in any private practice they may have. We have seen this time and again. It has happened everywhere Ebola has appeared. It has happened to medical workers from Sierra Leone, Liberia, Guinea, America and Britain among others in this crisis. One of the prime methods by which Ebola spreads is the medical worker, because the medical worker comes into close contact with so many patients, Ebola and non-Ebola, during the course of the working day. Given that the success of treatment is very poor to begin with and it carries with it the spread of further infections through the medical worker, we should  ask ourselves whether it makes sense to continue using health care workers to treat Ebola. We have a limited number of health care workers who we need for other illnesses that can be addressed successfully. We already have lost a significant percentage of our health care workers in a thus-far losing cause. In Liberia the health care system has virtually collapsed. In Uganda, in a much smaller outbreak, there was  a near-revolt at the main Ebola hospital. The WHO and MSF’s solution is to throw more medical resources at the problem. More treatment centers, more doctors, more nurses. This is understandable. These are medical organizations and they are looking for a medical response. But even if you could recruit the required medical workers (probably thousands not hundreds) from abroad, which is doubtful, Ebola would love this response. BECAUSE EBOLA KNOWS IT CAN SURVIVE AND SPREAD THROUGH THE HEALTH WORKER.  From East Africa to West Africa, health workers have been infected through their PPEs and no one has been able to conclusively explain how it has been happening. In tropical African conditions these protective suits are reportedly virtually impossible to wear and work with for any length of time. Isolation centers, as opposed to treatment centers, would reduce or eliminate the need for PPE-clad health care workers to be in direct contact with symptomatic Ebola patients.

(3)    So who would tend to the Ebola patients in the isolation centers? Who would perform the routine duties of cleaning up and assisting with feeding? Why would Ebola sufferers ever consent to admit themselves into a facility without doctors and nurses? For a start these facilities would still be provided with all the range of medicines that are currently being used to treat the symptoms of Ebola. And the administration of these medicines would be under the overall direction of qualified health care workers, albeit ones not in face to face contact with the patients (in a similar manner to which a general in war never sees the troops he’s fighting). Hands-on care of patients would be effected by two classes of people: relatives of patients and Ebola survivors. And what incentive would these classes have to perform these duties? MONEY. PAY THE PATIENTS AND PAY THE RELATIVES AND PAY THE SURVIVORS. ATTACK EBOLA MORE DIRECTLY WITH MONEY. USE MONEY TO CHANGE THE BEHAVIOUR OF THOSE WHOM EBOLA HAS DIRECTLY AFFECTED. We should pay the relatives and the survivors even more handsomely than we are now paying the doctors and nurses to look after Ebola patients. Not only that, we should pay for the Ebola patients themselves to come into the isolation centers. And we should pay them daily to stay in the centers. Even if, in the process we end up paying millions for some ordinary headaches. The overall goal is to isolate all potential Ebola patients from the rest of the populace. If we were to announce, say, that every Ebola patient who enters an Ebola facility accompanied by a relative would receive an immediate cash payment of one million leones, surely, surely we would quickly discover many new Ebola patients. Some genuine, some not so genuine, but these could be quickly weeded out by temperature test, clinical examination and a blood test. Survivors and relatives of genuine patients would be required to stay in separate facilities on the Ebola premises and to provide day to day care for their patients. They would have full access to PPEs. And they should be paid on a daily basis exactly as though they were doctors or nurses. Patient care by relatives carries added advantages: it eliminates the anguish and guilt that surely prevents many from bringing in their relatives for treatment (imagine a mother giving up her only child to a distant Ebola center); and it eliminates the fear among some sections of the populace that the Ebola facilities might themselves be poisoning patients. However these relatives would themselves need to be monitored after their duties at the center have ended, to ensure they themselves have not become infected. Patient care by relatives transfers the risk of infections arising within the hospital from the health care worker to the patient’s relative, but with a significant reduction of that risk: the relative is responsible for one patient, not many as with the health care worker. Ebola survivors, who are supposed to have immunity, could be used to care for those patients who present without relatives. They too should be paid equally handsomely on a daily basis. The Ebola isolation centers should provide care givers and patients with all the necessities of life, including three nourishing meals daily.

Conclusions: Patient care by relatives is not a new idea. It was tried in Uganda, in a much less desperate situation ( ). The costs of paying patients, relatives and survivors would not be prohibitive compared to the sums of money that are currently being discussed. If you imagine, for argument’s sake, five thousand patients each receiving with their relatives a total of one million leones, the cost would be five billion leones, a little more than one million USD. This is far less than the budgets that are currently being discussed.