Doctors Without Borders Fight on Ebola's Front Lines
Steve Mirsky: Welcome to Scientific American's Science Talk, hosted on November 14, 2014. I am Steve Mirsky. We're going to talk about Ebola again with two experts, Stanford's David Relman, an infectious disease specialist will offer some thoughts later in the episode, but first our health and medicine correspondent, Dina Fine Maron, was at the recent annual conference of the American Society of Tropical Medicine and Hygiene in New Orleans. On November 5th she spoke to Armand Sprecher of Doctors Without Borders. He's been on the front lines against Ebola in Guinea and Liberia.
Dina Fine Maron: Last night there was an Ebola session where you said some very interesting comments, in part related to the mortality that you're seeing in the field right now at the many Doctors Without Borders clinics. Can you tell us a little bit more about the age distribution you're seeing there?
Armand Sprecher: Well, what we were presenting last night confirms what people on the ground have seen for a long time, is that young children don't do with Ebola. The under-fives have the much higher risk of death than people over the age of five. It seems that older children actually do reasonably well compared to adults, but the young children do very poorly, and this is a – I mean it's bad that they're dying and it's also very, very difficult on the teams in the field; nobody likes to watch children die, and that takes a toll on the healthcare workers over time.
Dina Fine Maron: I know that we've been saying for a while now we don’t know about Ebola immunity, how long it can stay in your body, but you were talking a little bit about indeed how you've been trying to match Ebola orphans with people that you presume have immunity. Can you speak to that?
Armand Sprecher: Well, we assume that peoples' immunity will last at least the duration of the outbreak. And so one of the things we've been able to do is take advantage of, for example, women who've recovered from Ebola who choose to remain around so that they can take care of the infants who have lost their mothers and need someone to look after them. Because the healthcare workers themselves are challenged by their protective gear to remain in the high-risk zone for any length of time, and infants need a long continuity of care that is difficult to provide otherwise.
Dina Fine Maron: I know in the United States there's been a lot of talk about lessons learned with Ebola that some say are applicable to West Africa. Considering a lot of the lessons learned have to do more with dialysis, from my understanding, and potassium replacement, things like that, how applicable are those lessons for a low-resource setting?
Armand Sprecher: Well, so dialysis is difficult to do, or would be very difficult and very dangerous to do in West Africa. But potassium supplementation is fairly easy to do. And the measurement of potassium levels is not too difficult, and we're bringing laboratory equipment online to be able to follow that and to help guide supplementation. So there are some things that are unlikely to happen, but there are some things that will happen.
Dina Fine Maron: I know it hasn't been a traditional space for Doctors Without Borders to be involved in drug development, but now that Doctors Without Borders is taking such a lead in this particular response in that way is Doctors Without Borders thinking about shifting its focus or taking more of a drug development funding approach?
Armand Sprecher: Well, so one of the things we have to realize is that the in-house competency to negotiate the regulatory pathway and run trials is not necessarily there. So what we've decided to is to partner up with organizations that do do this for a living and to facilitate the trials and find what our space is in getting those trials done, because we, despite our discomfort with the subject matter and a longstanding difficult relationship with pharmaceutical companies, we want these things to be available, and so we have to do what we have to do to get that to happen.
Dina Fine Maron: Can you comment on how many MSF employees or volunteers in the field in West Africa have either become sick with Ebola or unfortunately died?
Armand Sprecher: So I believe the number right now stands at 23 have become sick and 13 of whom have died, unfortunately. Twenty of them have been national staff, so people in these countries that we employ to work in the management units and to work in the community, and three of whom have been international staff. All three of the international staff were evacuated to Europe or North America and cared for, and fortunately have all done quite well.
The concerning issue, of course, is how do these people become sick; do we have to do something to our work practices to keep this from happening. What we've learned, at least from the national staff, is that these people eventually go home, they don’t work 24 hours a day, and when they go back to their home community with their families and friends and whatnot they come into the same contact with Ebola that everyone else who lives in these countries does. And so while we can protect them from work risks within the work setting, we have very little influence over how they are protected at home. I mean we do what we can, and we've provided some home protection materials and so forth, but when somebody's – you know, one of our nurses goes home and their fiancé has Ebola and dies of Ebola, that person is going to take care of their fiancé, like anyone else would, and it is very difficult to distance yourself from a loved one when they're sick, and that kind of contact is difficult to manage.
Dina Fine Maron: Now that there's more of an influx of personnel aid coming to the field from Cuba, from the United States, from other African nations, including Kenya, does there need to be some sort of entity that is coordinating the people that are coming in and how they will be responding, or is Doctors Without Borders kind of taking on that?
Armand Sprecher: I sincerely hope that we're not taking on that role, just because that's going to be a lot of work. And I don’t know that we have the mandate to do that. What has been requested of us has been to train these people, to bring them up to speed so that they can work safely in West Africa. And we are doing our best to respond to that, however, we do not have, you know, the capacity to train everybody who wants to be trained and respond to the outbreak in the way that we'd like to respond. So we're doing our best to accommodate requests.
And fortunately other organizations are also stepping up. So the CDC has launched a training program that more or less does the same thing we do; they came into our training program and did a copy-paste maneuver that essentially allowed them to do what we were doing. And I believe I am International Medical Corps is also – we trained them some time ago, they've been at it for a little while now, and now they're taking on some interest in training people, and I think they're setting up their training program in West Africa.
Dina Fine Maron: And how many Doctors Without Borders clinics are there actually in West Africa right now for Ebola?
Armand Sprecher: Well, at least for the Ebola management centers we have six at the moment, and then there are a number of smaller transit units that we support. I think there are three or four of those. So that has a total of probably 650 bed of capacity. And we have about 280 or so staff that we send into West Africa, or have present in West Africa at the moment, and about 3,000, a bit more than 3,000 national staff employed. Now of course we do more than just run the treatment units. We have people out in the communities doing health promotion, engaging in surveillance, helping to arrange for safe burials, doing household disinfection. And very importantly, in, for example, in Monrovia, helping to try and get the normal healthcare system back online so that people are less likely to die of things like malaria and normal diarrheal disease and the things that are the challenges on any given day at West Africa.
Dina Fine Maron: Of the 20 nationals that became ill with Ebola from Doctors Without Borders, were those primarily clinicians or were they logistics officers or nurses?
Armand Sprecher: It's been all over. I mean we've had people who have been health promoters, hygienists, nurses, nursing assistants, drivers. Again, because the primary risk for these people is back home, there's no distinction between a clinician and a non-clinician once you get home. Except that perhaps the clinical people are under some pressure in their communities to provide informal medical services outside of the work environment, and that is a risk that is probably significant and difficult to control.
Dina Fine Maron: Can you speak to what a home health kit is exactly, how many have been distributed, and what signs there may be that it's working or not working?
Armand Sprecher: Well, so the home health kit that we are distributing consists of masks, gloves, gowns, buckets, chlorine, soap, and a few other things that don’t come readily to mind. We have distributed 47,000 of them so far out of a targeted 70,000. We are distributing them to high-risk groups, like taxi drivers, in households that are in high-risk areas, and to families of cases that come to us.
Dina Fine Maron: And how would you know whether or not they were working effectively?
Armand Sprecher: Oh, right. That would require some digging into the numbers, because the primary effect would be fewer cases coming to the management centers. But if you have fewer cases coming you don’t know that it's because of that. So we would have to go and say looking into contacts of cases where we had distributed a kit do we have fewer secondary cases in those families where a kit was distributed as opposed to families where kits were not distributed. And we can probably dig down and maybe get those numbers; it depends on how good a job we've done keeping track of who got kits where and pairing that up with the contact tracing data. So that would be an interesting study to do, and maybe we'll do it.
Dina Fine Maron: And the final question I wanted to ask you is what should we be doing right now, both to prepare for Ebola in the coming months or perhaps years, as well as future diseases that may carry even a greater risk of transmissibility than Ebola?
Armand Sprecher: Well, so preparing for future outbreaks, one of the most important things we could do now would be to get through the clinical trials to have effective therapeutics and vaccines available. If we had had those back in March we probably wouldn't be where we are today. A lot of the propagation of the outbreak occurred because people did not see an advantage in seeking care or being traced as contacts, and so eluded surveillance systems and remained sick in the community and producing disease-transmission that we were unable to control. If we had had something in the Ebola management centers that would be an incentive to come, so something that significantly reduced the case fatality ratio, that would've enabled us to bring in more people earlier in the course of their disease and reduce community transmission. And then vaccines are a very strong incentive for contacts to step forward and announce themselves, and the prospect of a therapeutic is a good reason to answer the door every day when somebody comes to check and see how you're doing.
Steve Mirsky: Earlier this week Doctors Without Borders announced that in the next few weeks they will begin clinical trials of three potential treatments against Ebola; two are antiviral drugs, one is the administration of blood samples from people who have survived Ebola, the blood would presumably contain antibodies against the virus. Two experimental vaccines have also been fast-tracked into trials.
David Relman is Chief of Infectious Diseases at the Palo Alto VA Healthcare System. He's also Co-Director of Stanford University's Center for International Security and Cooperation and chairs the forum on microbial threats of the Institute of Medicine, the health arm of the National Academy of Sciences. On October 23th Relman was in New York City to give a talk at the Albert Einstein College of Medicine. I caught up with him after his address. We mostly discussed his work on the human microbiome, that's all the tiny organisms that live on and in you, and I'll play that part of our conversation in an upcoming episode. We also took a few minutes to talk about Ebola.
As you sit as a spectator as the Ebola situation plays out, what are your reactions to how it's being handled and how here in America the public has reacted to it?
David Relman: Yeah. Well, three things. First, it's just a reminder that despite there being largely neutral or beneficial microbes on this planet with respect to us, there are still are exceedingly important, albeit very rare, but incredibly important disease-causing agents that will always find a means to encounter humans. In fact, will increasingly encounter humans as we continue to disturb the environment around us.
And that's point two, that what we're seeing now with this Ebola outbreak and lots of emerging disease outbreaks in recent years is the result of human modification of the environment around us and our intrusion into ecologic systems and cycles and life cycles of other organisms that were happening all the time in a relatively peaceful manner, because Ebola, for example, lives quite comfortably in certain bat species without causing disease. When we intrude upon the rain forests where these bats are found or cut those trees down and force the bats to now find other homes, we're bumping into these parts of the ecosystem that we simply hadn't before. And this is going to be the result when we encounter organisms that were adapted for some other host or some other environment and now they have an accidental introduction into the human population.
Steve Mirsky: Mm-hmm. Then there was a third, right? Yeah.
David Relman: And I think the third thing it will teach us and is teaching us how we need to be much more mindful about ecosystem balance and better intelligence on what are these forces that normally keep these interactions in an equilibrium state at peace and therefore what are the forces that we need to either maintain or restore in order to prevent these kinds of events from happening. Maybe the corollary is that we also will have to learn how to deal with the consequences when we can't manage things so well, when human population continues to expand and water supplies become diminished and climate is going to change, we're going to have to get a lot smarter about how to anticipate, but also respond to these kinds of outbreaks.
Steve Mirsky: Right. And the only way to anticipate is to have a really good surveillance system in place, which we didn’t have.
David Relman: Exactly. Exactly. And I think even now we should be much more aggressive about looking at what this virus is doing now that it's in people and propagating from one person to another in a way it had never done to our knowledge before, and looking at the evolution of this virus in nature, as well as trying to understand how do you counter it, what are the useful strategies, whether it's vaccines or drugs, and what else is out there that we need to be aware of.
Steve Mirsky: Yeah. I heard a report on NPR this morning that – and there are so many unintended consequences, and one of them that they're seeing now in Liberia, I think it was, is they're not vaccinating kids against things that we do have a vaccine for, because everybody's afraid to deal with any healthcare workers or anybody who could have had any contact with Ebola. So the cascade of negative effects that spread even more disease and have terrible economic consequences is just huge.
David Relman: Yeah. Acute unexpected and catastrophic disease always reveals the most vulnerable and fragile parts of our defense system, in this case the public health defense system. And the unfortunate factor or fact is that, and maybe it's because of this, this outbreak is flourishing in just the part of the world that had the most fragile public health infrastructure, as well as greatest degrees of mistrust in local government and governance systems. That's a terrible combination to have in play when something like Ebola emerges. Everything destabilizes very quickly and the whole system is like a house of cards, it falls apart very, very easily.
Steve Mirsky: I think – what do you think about this idea that anybody in the U.S. who's really concerned about getting an infectious disease should really just go out and get a flu shot?
David Relman: Absolutely. There are only 101 reasons why something as simple as a flu shot makes all the sense in the world right now, but one of the new reasons is come this winter the last thing the public health system needs is a whole bunch, meaning hundreds of thousands of people, who have fever with an ill-defined and undifferentiated illness who could have prevented those febrile illnesses by simply taking a flu shot. Because should Ebola show up more in this country every emergency room and clinic is going to have to be mindful of what does it mean to see someone with a fever and muscle aches and headache and even, you know, diarrhea. It would be a wonderful thing to be able to take influenza off the table and not have to worry about that in the midst of everything else.
Steve Mirsky: I got my flu shot two days after recording that interview. That's it for this episode. Get your science news at our Web site, www.ScientificAmerican.com. We have all of our Ebola coverage organized on a single Web page, just google "Scientific American" and "Ebola" and any of the first batch of articles that come up will take you to the main page, which is called "Ebola: What You Need to Know." And follow us on Twitter, where you'll get a tweet whenever a new item hits the Web site. Our Twitter name is @sciam.
For Scientific American Science Talk I am Steve Mirsky. Thanks for clicking on us.
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