Ambulances are scarce in areas of west Africa roiled by the Ebola outbreak, so when ill patients and their families need to go to the clinic they often turn to the next best thing—a motorcycle taxi. An ill passenger will wrap her arms around the driver’s waist and away they will go—sometimes driving an hour or so to get to a nearby clinic. During the journey a weak patient, clinging to the driver, may expel diarrhea and literally drape herself over the driver even as her bodily fluids permeate the seat. In the process the driver may get infected.
 
It’s a simple tale of disease transmission as patients are en route to get assistance, but it’s hard to track the scale of the problem because it’s nearly impossible to tease apart whether harmful Ebola exposures happened during transport or in other settings such as the funeral attended the week before that fateful ride.
 
“It’s a tangible risk,” says Jack Chow, professor of global health at Carnegie Mellon University and former assistant director general of the World Health Organization on HIV/AIDS, Tuberculosis and Malaria. Although guidelines have been prepared for travel on planes, he says, such precautions are still needed for community transport.
 
Once patients arrive at the hospital there are often not enough beds for everyone, which means another trip on a motorcycle to get home, potentially exacerbating the threat further. As Pres. Barack Obama said Tuesday, patients turned away from clinics are too often “sitting, waiting to die.”
 
The threat to motorcycle drivers and their passengers is obvious but flatbed trucks are not necessarily any safer. “The back of the truck has to be cleaned out between patients,” says William Fischer, a physician who helped to fight the Ebola epidemic in Guinea this past spring and is now back in the U.S. But getting the needed resources to clean the vehicle or cleaning it well enough can sometimes be a problem. Say someone who might have Ebola is crammed in the back of a flatbed truck next to someone who turns out “only” to have dengue fever—that, too, can lead to Ebola infection. Ideally, if numerous potential patients are squished together in the back of a truck they should each have donned personal protective equipment, but a lack of available gear often prevents that from happening. Such conditions mean that the very ride to receive evaluation and care can, in fact, lead to illness.
 
Cleaning these vehicles should not be that hard to do. Despite the fact that this Ebola virus has killed in such high numbers, it’s not that robust. “It’s actually a pretty fragile virus,” Fischer explains. Once the viral envelope is destroyed it cannot survive long-term in the environment (unlike viruses that easily live on surfaces such as norovirus and adenovirus). Indeed, Ebola can be destroyed with chlorine or soap and water. But those disinfectants can sometimes be hard to come by in west Africa. In addition, when the virus is encased in stool or vomit, it’s challenging for chlorine to penetrate that organic material and neutralize the threat. At any rate, if a driver manually cleans his motorcycle or truck before loading on more passengers but goes on to touch his mouth or eyes, that can lead to yet another infection. “These aren’t naive people, they are loving people who want to help each other but they just don’t have the resources to protect themselves,” Fischer says. “That bike driver cleaning his bike for his next passenger may do a good job cleaning, or maybe not, but in the process he may infect himself.”
 
Moreover, the driver, after dropping a patient off at the clinic, also has to become part of the Ebola contact tracing system—tracked by health authorities to ensure that if he does become symptomatic he will be isolated and treated rather than infect yet more customers and friends. Of course that’s easier said than done because the people tasked with doing so are chronically understaffed, making it hard to get the driver’s name and contact information before he speeds away.
 
Even with the new Ebola response effort announced by the White House on Tuesday—which includes an infusion of 3,000 U.S. military personnel to help respond to the outbreak and the promise to build additional Ebola treatment units as well as train up to 500 health care providers each week—that may not help to immediately address this transport concern. The U.S. Agency for International Development will support the outbreak response by helping to provide protective gear for households, but exactly when and how those will be deployed—and if taxi drivers would receive them—remains unclear. The package of kits are most immediately slated to target the 400,000 most vulnerable households in Liberia. So for now, drivers just can do their utmost to keep their vehicles clean, wash their hands and try to avoid the stool, urine, saliva or sexual fluids of infected people.