Viral haemorrhagic fever is a general term for a severe illness, sometimes associated with bleeding, that may be caused by a number of viruses. The term is usually applied to disease caused by Arenaviridae (Lassa fever, Junin and Machupo); Bunyaviridae (Crimean-Congo haemorrhagic fever, Rift Valley Fever, [and] Hantaan haemorrhagic fever); Filoviridae (Ebola and Marburg); and Flaviviridae (yellow fever, dengue, Omsk haemorrhagic fever, [and] Kyasanur forest disease).

World Health Organization[1]

The Good Samaritan gave Money to the Host where he had lodg’d his Patient, and said, TAKE CARE OF HIM, and what thou spendest more, I will repay thee.

Benjamin Franklin[2]

[If you’ve read this blog for very long, you know we paid a lot of attention to the Ebola outbreak of 2014 – 2015. Ebola – the version that broke out in 2014 – was and is an ugly customer, but actually it’s only one of a family of medical horrors. WHO[3] names them at the beginning of this piece, and there’s none I want in my home town [or yours, either]. Ebola’s relatives are worse even than the heroin epidemic that’s sweeping our benighted land. A user gets involved with heroin and its friends by an act of will; he [or she] takes a first dose and gets addicted. Hemorrhagic fevers [note the American spelling] jump out at us from friends and family, etc., and may infect even those who run away.

Of course we’ve made a lot of progress treating Ebola, or at least the version that scared us in 2014. In spite of early missteps, that epidemic is over, at least for now. As one commentator put it: “A stuttering, uncoordinated early response, which exposed the overwhelmed public health capacity of the region and claimed the lives of thousands, was followed by one of the most successful global partnerships between foreign and local governments and multinational aid [organizations] to stem an international health crisis.”[4]  Also, as we noted last time, there’s at least one vaccine in our future. Too bad we can’t fix the heroin problem the same way.

But this blog is about Ebola, and what remains to be done. Why dwell on that? Well, because Ebola may evolve and return; and its ugly relatives are still out there. Is it possible our recent success also set a pattern for defeating them the next time they appear? If so, are we learning from our success, or simply ignoring the hemorrhagic fevers on the theory that we’ll deal with them later?]

Dangers of Ebola

Let’s talk for a bit about how dangerous Ebola was in 2014. It was very bad for humans. WHO described it as “highly infectious, rapidly fatal, with a high mortality rate ….” It “spread through direct contact with body fluids (blood, stool, vomit, saliva, urine, sperm, etc.) of an infected person,” or by contact with surfaces or equipment, including linens, contaminated by body fluids from someone who was infected.[5] WHO also said that health workers were “between 21 and 32 times more likely to be infected with Ebola than people in the general adult population.”[6] Nurses and nurses’ aides were particularly vulnerable.

A lot of people died from Ebola, but even the lucky survivors may have problems today. These include mental health issues for “survivors and other family and community members,” and, possibly related, an “increasing recognition that Ebola virus may persist in selected body compartments of survivors.” If the virus persists can a survivor reintroduce it to an area “where transmission [was] previously … eliminated?”[7] Is it any wonder that the neighbors might worry?

Recent Trends

I don’t know about you, but in 2014 I saw the world intervene massively in West Africa to treat Ebola patients and contain an epidemic. It turned out that extraordinary measures weren’t needed because the more traditional methods of treating and isolating the disease broke the epidemic first. Fair enough, I thought; but at least the facilities we built and the people we trained will improve medical care in the area. But apparently that wasn’t the case. Why? Some of the projects were completed on time, but most weren’t completed at all, in large part because they were no longer needed to fight Ebola. The disease was already in retreat. [8]

So our extraordinary efforts didn’t strengthen the medical infrastructure of the infected areas? Apparently that’s the case. A recent study in Guinea,[9] for example, shows that today mothers and children have less access to health care than they had prior to the Ebola crisis. The situation has deteriorated, not improved, at least with respect to them.

  • Child births in hospitals and subsequent visits increased markedly prior to the Ebola outbreak; then reversed during the epidemic; then reversed again when the epidemic was over, but ultimately the trends stagnated;
  • The same happened with childhood vaccinations. They trended upward prior to the epidemic, then reversed during the epidemic[10] and, in some cases, continued to decrease in the post-epidemic period[11];
  • “Most maternal and child health indicators significantly declined during the Ebola virus disease outbreak in 2014. Despite a reduction in this negative trend in the post-outbreak period, the use of essential maternal and child health services have not recovered to their pre-outbreak levels, nor are they all on a course that suggests that they will recover without targeted interventions.”[12]

So why did this happen?  Is it because the women and children of Guinea are afraid of or simply don’t trust their health care providers?  Or have the providers died or left the area because of Ebola virus disease? Or is the local health infrastructure too damaged by the epidemic to function properly? Or are more than one of these factors in play?[13]

Whatever the answer, the experts seem to agree that a lot of work needs to be done to improve health services in West Africa.  “Targeting the root causes, preventing future epidemics, and improving access to health services for the millions affected by weak public health infrastructure will require the international health community … to show unwavering commitment to the long, slow, collaborative work required for meaningful capacity building.”[14] And why should the “international community” be concerned about health and epidemics in remote places? Well, because these days epidemics are tourists; they may start in one place, but like humans they can travel just about anywhere.

Conclusion

So I think old Ben Franklin had it right. The developed world, like the Good Samaritan, should work to strengthen the health infrastructure in places like West Africa. Otherwise epidemics may pop up where folks are most unprepared to fight them, and we’ll all lose valuable time and possibly lives as a result. Help the people there now and most likely we’ll help ourselves later

At least that’s what I think. And who am I? Why Phil, the blog philosopher.

[1] The quote is from the World Health Organization [WHO]. See World Health Organization, Health Topics, Haemorrhagic Fevers, Viral, at http://www.who.int/topics/haemorrhagic_fevers_viral/en/ We’ve added some semicolons, hopefully for clarity, but have not changed the spelling of “haemorrhagic.” In the U.S., of course, we would drop the “a,” to spell it “hemorrhagic.”

[2] See Franklin, Silence Dogood, the Busy Body, and Early Writings (LOA, 1987, 2002) at p. 170, Compassion and Regard for the Sick (March 25, 1731)

[3] WHO’s official web site has lots of information on diseases worldwide. It doesn’t focus, only on Ebola. See World Health Organization, at  http://www.who.int/en/

[4] See The Lancet, Comment, Siedner & Kraemer, The end of the Ebola virus disease epidemic: has the work just begun? (February 22, 2017 (online)), available at http://thelancet.com/journals/langlo/article/PIIS2214-109X(17)30079-7/fulltext?elsca1=etoc

[5] See World Health Organization, Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola (December 2015), at p. 6, available at: http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.4_eng.pdf?ua=1&ua=1&ua=1

[6] See World Health Organization, Preliminary Report, Health Worker Ebola infections  in Guinea, Liberia and Sierra Leone (21 May 2015), available at http://apps.who.int/iris/bitstream/10665/171823/1/WHO_EVD_SDS_REPORT_2015.1_eng.pdf?ua=1

[7] See World Health Organization, Interim Guidance, Clinical care for survivors of Ebola virus disease  (April 2016 ), at p. 5, available at http://apps.who.int/iris/bitstream/10665/204235/1/WHO_EVD_OHE_PED_16.1_eng.pdf

[8] See, e.g., The Washington Post, Sieff, U.S.-built Ebola treatment centers in Liberia are nearly empty as outbreak fades (January 18, 2015), available at https://www.washingtonpost.com/world/africa/us-built-ebola-treatment-centers-in-liberia-are-nearly-empty-as-disease-fades/2015/01/18/9acc3e2c-9b52-11e4-86a3-1b56f64925f6_story.html

[9] See The Lancet, Article, Delamou et al., Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study (April 2017), available at http://thelancet.com/pdfs/journals/langlo/PIIS2214-109X(17)30079-7.pdf

[10] Id. “Similarly, the increasing trend in child vaccination completion during the pre-epidemic period was followed by significant immediate and trend reductions across most vaccine types”

[11] Id.  Especially vaccinations for polio, measles and yellow fever.

[12] Id.

[13] See The Lancet, Comment, Siedner & Kraemer, The end of the Ebola virus disease epidemic: has the work just begun? (February 22, 2017 (online)), available at http://thelancet.com/journals/langlo/article/PIIS2214-109X(17)30079-7/fulltext?elsca1=etoc

[14] Id.

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