Ebola has pummeled healthcare systems in west Africa and laid bare health infrastructure issues that may not have otherwise been so readily apparent. It has also prompted aid organizations and governments to do some soul-searching about what should be done to prepare for the future.
Ebola expert Daniel Bausch, a professor in the Department of Tropical Medicine at Tulane University, has been consulting with groups including the World Health Organization to ramp up its Ebola response. On the sidelines of the American Society of Tropical Medicine and Hygiene conference in New Orleans this week he sat down with Scientific American editor Dina Fine Maron to discuss some of the hurdles facing health care workers in West Africa.
(For the complete audio, including a discussion about why certain individuals are surviving Ebola, how to prepare for future similar threats and changing personal protective equipment to better protect healthcare workers, please tune in to the Science Talk podcast here.)
[An edited transcript of an interview excerpt follows.]
Why didn't we see Ebola coming in west Africa?
Prior to this outbreak the largest outbreak that we've ever had was 425 cases in the northern area of Uganda in 2000 and 2001.  So while that was a tragedy for the people who lived in that relatively remote region of Uganda, this is something that doesn't really compare with the number of cases of HIV and TB and malaria and many other diseases on a daily basis.  We really had in our minds that Ebola is the sort of disease that appears sporadically in remote regions of Africa and causes extreme tragedy for those populations but not really something that we need to have on our radar in the bigger picture.
An Ebola patient produces 30 to 40 times the amount of medical waste that normal patients generate. How can that level of waste be handled safely, both in west Africa and here in the U.S.?
So much of that waste, of course, is the PPE, or personal protective equipment, that people need to wear in order to treat these patients. Almost all of it is disposable.  So each time a healthcare worker goes in to visit and treat an Ebola patient that person can stay in for maybe an hour and a half, two hours tops, and then has to go through the doffing and decontamination procedure.  And then all that gets thrown out, so there's a huge amount of waste.
What about the amount of waste from the patients themselves?
Relatively small amount of waste comes from the patient himself or herself. People are having eight to 10 liters a day of diarrheal stools during the acute phases of the illness and then there’s all the other routine waste like needles and gloves.
So how do you handle all that waste, and what risks does it pose?
In Africa [the waste] would get taken to a burn pit and then incinerated.  We don't have a huge problem with environmental contamination in that way in terms of the virus.  It's not particularly stable in the environment, so in those burn pits we don't really have a big concern about [waste] not completely getting burned or leaking into the groundwater and that sort of thing.  That's not how people get infected with this virus.
In the United States, of course, we are somewhat beholden to higher tech solutions, which in some ways are a little bit more problematic in terms of treating all that waste, and we need autoclaves or incinerators that can handle that sort of thing.  It's not the actual inactivation that's particularly difficult; it's just the process of getting the waste from, of course, the frontline of care and interaction with the patients safely to the place where it can be incinerated or autoclaved.
What sort of unexpected obstacles are responders coming up against?
With the U.S. government response in Liberia, responders discovered that the airstrip at the airport in Monrovia was not adequate actually for the planes that they needed to fly in supplies.  And so even before you get to anything related to Ebola they needed to repave the airstrip in order to get that in.  And that sort of thing is not unusual.
Are there any differences between people who are surviving Ebola and those who aren’t in west Africa?
[The data] suggest young children and older people are dying. In this area of west Africa 45 is an older person.  Life expectancy in some areas of Guinea, Sierra Leone, Liberia—you know—is probably around 50, so someone who's 45 can be considered older.
This is actually like cholera—it’s really the very young and very old who die, those who just can’t tolerate the volume loss of having eight or 10 liters of diarrheal stool every day.
Data presented by Doctors Without Borders also suggests that when it comes to surviving Ebola it does not seem to matter what day in the course of the disease an Ebola patient shows up at the clinic in west Africa. Why is that? Is that about the level of care available?
Doctors Without Borders would agree that that data is preliminary, and we still need to dig deeper and sort it out. But one thing that’s going on there is getting treatment earlier only matters if there's treatment. So if you come on day two, then some would say, "This is great, you're here on day two, you're here early and now we can give the intravenous fluids if you need them and manage your electrolytes and make sure your potassium levels are adequate and those sorts of things."  Then of course showing up early will be better. 

But if there's none of that available, if you have a situation where people can't give you those fluids, can't [replenish] your potassium and different things that you need, then, of course there's no association with coming early because it doesn't impact the course of disease.