Ebola: risks and inequalities

As we mull over the latest reports of Ebola in New York, does anyone recall how many people in the U.S. died last season from flu? In all, 108 children and probably 20 times that many adults. It was not a bad season. In 2009, we lost 348 children, and roughly 50,000 adults, out of the third of a million flu deaths worldwide.

No United States citizen has died from Ebola. We have had one death on our shores, a Liberian national. For comparison, about 51 people here are killed annually by lightning. Using an iPhone on a golf course is staggeringly more dangerous than having an Ebola patient in Massachusetts General Hospital or Tufts hospitals would be to us.

Nor is Ebola uniquely lethal if contracted. Rabies kills every unvaccinated soul it touches. Inhalational Anthrax, HIV, Pneumonic Plague or Glanders all have untreated case death rates well above 90 percent. By contrast, Ebola seems to have about a 80 percent mortality rate untreated and only half that when victims are treated from the onset of fever. This is only a few percent more than Eastern Equine Encephalitis, which is endemic in Massachusetts. Grim, but still better odds than flipping a coin.

So it’s reasonable to ask, why are we so frightened of Ebola that we cross the street to avoid physicians working in a hospital with a case? Why do tabloid newspapers trumpet the “arrival” of Ebola, and politicians scurry to show how tough they’ll be to anyone returning from West Africa? Well, you might reply, because it’s so infectious. But that also would be off the mark.

Infectivity is the ability of a pathogen to start an infection after exposure, while infectiousness is the ability to be transmitted from one host to another. Ebola has high infectivity. By the late stages of infection, literally billions of viral particles are present in the victim’s blood, vomit and feces. Some particles may even be in their sweat and saliva. So once exposure has occurred, the odds of infection are high. Yet Ebola is poorly infectious. It can only be transmitted by direct contact with body fluid from a person with acute symptoms.

Ebola is not, contrary to what some media figures have claimed, spread in the air. Influenza, tuberculosis or cold viruses can literally ride air currents for minutes, suspended on microscopic sputum droplets. When they land on surfaces, they are resistant to desiccation. By contrast, Ebola might be expelled from splatters of body fluids, but these will not travel any distance. Sneezing or coughing are not part of the symptoms. And the virus cannot survive desiccation. Without direct contact, there is no exposure.

People near a victim of Ebola do not usually become infected; caretakers do. We cannot get Ebola from a bowling ball or subway grip, unless we create a scenario where an infected person passed vomit, blood or fecal materials onto it just before we touched it. In the developed world, our infrastructure makes this highly improbable. We monitor temperatures, trace contacts, mandate quarantines and hospitalize promptly. For all the missteps in Dallas or New York, the more infectious an Ebola victim becomes here, the less likely they are to infect family and friends, let alone strangers.

If we’re shocked by Ebola’s appearance on our shores, that’s because we’ve been able to ignore its periodic outbreaks in comfortably distant places. Like a host of recent viral diseases, Ebola is scarcely emergent. It’s been endemic in central African villages since the 1970’s at least, and, like HIV, has animal hosts. And as with HIV, Americans’ response to the outbreak is linked in complicated ways with fears of bodies deemed to be dangerously “other.”

These fears have been shaped by lengthy histories of inequality and exploitation. Poverty, poor infrastructure and weak political legitimacy all characterize the affected countries of Liberia, Sierra Leone, Guinea and now Mali. Liberia and Sierra Leone are post-conflict states. The priority for their governments and foreign donors has been to rebuild their militaries, not their health care systems.

The tragedy for these countries is less about lacking high technology -- simple oral rehydration therapy can reduce mortality -- than lack of the foundational: medical supplies and health workers; personnel to trace possible exposures; roads and vehicles to move victims, supplies and building materials; hospitals that allow effective isolation while protecting staff from exposure; means of safely removing waste and burying the dead.

Without such basic infrastructure, Ebola victims either move though the community and beyond as they become increasingly infective, or are quarantined in their homes and further weakened by food and clean water shortages. Their caregivers, unable to obtain even protective gloves and handwashing supplies, are exposed to bodily fluids. Some patients reach inadequate clinics or mere “holding centers,” ending their lives collapsed in chairs, prostrate on benches or the floor. There is no isolation, and little to no treatment. Sometimes, those they leave behind commit suicide rather than face a similar end.

Survivors can see their entire families wiped out. Here is the story of David, as told to a pastor from Sierra Leone who is in contact with Rosalind Shaw. David lost his wife when she went to a hospital during pregnancy complications: “I came back home and buried my wife. Two days later the report came from the hospital showing that my wife died of Ebola and the house was quarantined. In less than twenty-one days seven other members of my family died of Ebola…Only two of us survived in this house…I am finished. I don’t know what to do…I wonder when this pain will go away.”

Ebola also undermines the networks of support through which people care for each other. Even simple daily connections like greeting and taking leave in these countries typically involve multiple human touches. That’s now problematized. Yet many individuals and community organizations are responding with remarkable creativity. In some places, local pastors are visiting quarantined homes, bringing health information, food, water, soap and crucial emotional support. Caregivers are improvising their own protective clothing from plastic bags. Survivors with antibodies to Ebola are donating blood and working in treatment centers.

But this is not enough. A robust national and global response is needed that emphasizes care and prevention equally. If we want to protect ourselves, the first step is to help protect others far from our daily lives.

What can you do? You can raise funds for Medecins Sans Frontieres, Partners in Health, Catholic Relief Services, Africare or Samaritan’s Purse. You can tell Congress that you want more U.S. support for the fight against Ebola in West Africa. You can counter misinformation about the spread of Ebola. And you can share personal stories -- like the one above -- from doctors, community activists and survivors.