Ebola has arrived in Spain, and many in Britain are now suggesting that we screen new arrivals at our airports for the disease. But deadly as the virus is, it is also easily destroyed, Tom Chivers reports
In a hospital somewhere in a rural part of sub-Saharan Africa, a patient presents with an unknown disease. That sounds more dramatic than it would appear on the ground – the patient has a fever, perhaps a headache, perhaps nausea, symptoms that could mean anything. Most of the time it will be one of the waterborne diseases that are rife in these poverty-stricken places. But in this case, it is something else.
Ebola is a frightening disease that can kill as many as nine out of every 10 people infected. It is painful and horrible; it kills by making its victims bleed to death internally. There is no cure or vaccine. And right now, in Liberia, Sierra Leone and Nigeria, it is killing people – 670 at least, at the time of writing, have died. More than 1,000 people have been infected in this outbreak, making it the world’s worst ever: there have been only around 2,300 deaths in all the previous outbreaks.
Most of the time, the disease sits pretty harmlessly in fruit bat populations. But every so often, says Prof John Oxford, a virologist at the University of London, it makes an unlikely leap into humans. “Perhaps someone eats bush meat, or comes into contact with bats. But then the virus makes it into a human body, and that human is pretty unlucky.
“After about a week, you get a huge frontal headache, a high temperature, maybe a rash. Then a few days later you get nausea, vomiting, diarrhoea – and then bleeding, from the eyes, from the mouth, from the backside.” And from there, if you are left untreated, you will probably die.
For the men and women on the front line, the key is identifying the disease as early as possible. By the time an outbreak has been noticed, your best chance of containing it has long gone, says Prof Paul Hunter, a specialist in health protection at the University of East Anglia, who has dealt with outbreaks of infectious diseases in Congo and Sudan. Most doctors in Sierra Leone don’t have equipment to do blood tests or other diagnostic procedures that would be straightforward in Western hospitals. “The early symptoms are generic, so your judgment on whether the case in front of you is something dangerous depends on what’s going on in the region – if there’s been an outbreak of typhus, for instance.”
What that means, though, is that in those early, crucial days of an outbreak, things are much more difficult. Later on, Ebola is, in a gruesome way, easier to manage than some other diseases – the fact that it is a haemorrhagic fever, that it has this terrible but distinctive bleeding in its late stages, means that by the time the patient is dead, you probably know the cause. With other diseases, says Hunter, you could still be guessing.
But once doctors know what they are dealing with, the question is how to stop it from spreading. And in one sense, we’re lucky – as frightening and unpleasant as Ebola is, it is not, actually, very infectious. “It doesn’t spread very easily – it’s not an airborne virus. You need to get close to fluids, such as blood or vomit,” Oxford says. This means its “reproductive number” – how many people are infected, on average, by each carrier – is very low: about one, compared to 12 for measles. What’s more, it’s not very hardy. “We know it as a filovirus – not a typical virus, which looks like a kind of tiny football, but this extraordinary-looking thread, like a piece of cotton.” Simply washing one’s hands destroys the long, fragile virus.
The trouble is that Ebola, as mentioned, is both hard to diagnose in its early stages, and frightening. “It’s not easy to tell that you’ve got Ebola. If you present at a hospital in west Africa with vomiting, you’ll probably be diagnosed as having cholera,” says Oxford. “So nurses and doctors won’t take appropriate precautions and will become infected.” And once a case has been detected, it terrifies people. “A lot of hospital staff abscond when the diagnosis is made,” Hunter says. “And lots of people who were on the plane with the first man who died in Nigeria have absconded, because they didn’t want to be quarantined.”
Local practices in the affected regions do not help to slow the disease. The Ebola virus can survive for several days outside the body, and in much of west Africa it is common at funerals to touch the skin of the deceased. In a haemorraghic fever victim, that means the skin will be covered with the still infectious virus that killed them. “If you touch the person’s face or something, and then touch your eyes or mouth without first having washed your hands, you could be infected,” Oxford says.
He is keen that the World Health Organisation and other groups work with local religious leaders and faith healers – “it might be odd, a professor of virology saying that, but they are the ones people trust”. The trust in Western medicine, sadly, is lacking. “When I was in east Africa, all sorts of rumours were flying around when we tried to get blood samples – it’s a Western plot to give us HIV/Aids, that sort of thing,” Hunter says. He refers to a terrible case in 2008, when French aid workers took babies out of Chad. “That played very badly – people said, you have to be careful with white people, they want to steal your babies.”
Dr Tim Jagatic is a Canadian doctor with Médecins Sans Frontières, who has just come back to Europe after facing the outbreak in Sierra Leone. “The ‘hospital’ is a group of tents in a clearing in the jungle, away from the population to reduce the risk,” he says. “It’s a low-resource setting, just doing basic medicine: hydration, nutrition, fever control, promoting hygiene.” But even with such limited tools, his team has brought the death rate of patients down from around 90 per cent to below 60 per cent, at some risk to themselves (“There is a sense of – not fear, but precaution. If you don’t pay attention, you do put yourself at risk”). And, equally importantly, he is addressing the two problems of poor disease control and the lack of trust. “What we’re doing is gaining trust, dispelling rumours – showing that we’re not here to steal organs or take blood, we’re providing food, providing medicine.” And they’re promoting the basic hygiene that will stop the next outbreak: “They go away knowing to wash their hands, and they tell their families.”
All three men agree that the risk of the disease making it to Britain is slim, and if it does, the methods of hygiene applied in Western hospitals would ensure that it didn’t spread far. But the thought of the disease in Europe or America is instructive. “If there was a disease in the UK with a similar mortality rate and risk of spread, potential new treatments would be made available,” says Jeremy Farrar, a professor of tropical medicine and the head of the medical charity the Wellcome Trust.
He has pointed out in the past that the response to Ebola is essentially the same now as it was when it was first noticed in 1976 in Zaire and Sudan: a response he calls “shut you away and bury you nicely”. The sporadic nature of the disease and the fact that it survives in bats between outbreaks makes it harder to come up with vaccines and cures, but the fact that it is exclusively a disease of sub-Saharan Africa means that the urge even to try has been disgracefully lacking in the West. There is still much to learn about the disease: for example, Farrar points out, the mortality rate of this outbreak, though still high, is lower than we normally expect, and we don’t know why. (The lower mortality rate may be the reason this year’s outbreak has spread so widely and rapidly: normally Ebola kills its victims too quickly for it to spread to many people.) In general, the way the virus behaves in the human body is poorly understood.
Perhaps that will change in the future. But for now, Oxford says, “it’s all about calming people down”. The current outbreak will die out relatively soon, he says, because the various governments have started to take steps – quarantining, improved hygiene, altered funeral practices – that will break the chain of infection. And, as unexciting as it sounds, the way the disease will be defeated will probably not be marvellous medical breakthroughs, but getting more people to wash their hands.