Steven Hatch is an associate professor of medicine at the University of Massachusetts Medical School, specializing in infectious disease and immunology. He is the author of Inferno: A Doctor’s Ebola Story.
Earlier this month, the World Health Organization announced that it had stopped clinical trials it had been performing on Ebola therapies in the Democratic Republic of the Congo (DRC) because two of the treatments were clearly and unambiguously saving lives. In effect, the announcement served as a declaration of victory in the war against the virus. Since then, we’ve been living in a world where Ebola has been defanged. What was once a killer that struck fear into billions of people has now been shorn of its terrifying identity.
Five years ago, as I worked in an Ebola Treatment Unit (ETU) in Liberia, these two drugs – REGN-EB3 and mAb114 – would have been a pipe dream, the answer to the prayers of millions caught up in Ebola’s deadly grip. While the West African outbreak of 2014-15 “only” resulted in around 30,000 infections with more than 10,000 dead, the affairs of the three primary countries of Liberia, Sierra Leone and Guinea ground to a halt. Business stopped. People remained indoors. Clinics and hospitals closed up shop. Distrust reigned supreme. And many more people who didn’t have Ebola died because of these effects. The actual number of infections did not capture the level of misery these countries experienced. Effective drugs would have seemed like manna from heaven in such an environment.
Mostly, what I did in the ETU was provide what is euphemistically termed “supportive care.” It’s a code phrase that means, “We have no specific drugs to help, but we’ll do what we can.” And what we could wasn’t much. The mortality rate in our unit was about 50 per cent, similar to other ETUs at the time. A fair amount of my effort was to watch people die while treating them with as much dignity as possible.
I had come to Liberia for the first time only a few months before the outbreak; when I saw the virus barrelling its way through the country in early 2014, I resolved to go help my new friends, and within a few months, I became part of the massive local and international effort to bring it to heel.
Some experimental Ebola therapies were introduced during this time. A drug called ZMapp had been developed years before in the United States, but there wasn’t enough of the drug to formally test its effectiveness, so a few people received it under what is called a “compassionate protocol.” A few other drugs, from the reasonable to the fanciful, were selectively distributed, but none of them were studied in any organized manner, and so nobody knew if any of them had any lifesaving effect.
However, the scale of the tragedy spurred international scientific groups to have a more deliberate approach when the next big outbreak came. The current outbreak in the DRC, which started more than a year ago, provided just such an opportunity. It led to a trial of four potential medications, including ZMapp and the two that were shown to be lifesaving. Since Ebola made its debut on the international health scene in 1976, these trials marked the first time in which we proved there were specific, effective treatments against the virus. Historically, Ebola killed roughly 70 per cent of its victims; the two new treatments studied in the DRC dropped the mortality rate to half that, and in patients who managed to receive the drugs early in the illness, the mortality rate had dropped to an astonishing 10 per cent.
And this hasn’t been the only good news. Not only are there now effective treatments, but a safe and highly effective vaccine, rVSV-ZEBOV, has been developed. Thus far, it has been given to more than 100,000 people in the region. There is little question that without this vaccination campaign, the current outbreak would be a great deal worse than it is, possibly as large and devastating as the West African outbreak.
In such a moment of triumph, it is useful to take stock of Ebola’s place in our collective imagination, and consider how and why it managed to strike such fear into people when other viruses no less harmful are not given the same notoriety. For instance, influenza is often thought of as an annual nuisance, but the more virulent strains can be as lethal as Ebola, and are much more easily transmitted. SARS – no stranger to Canadian soil – is an easily transmitted respiratory virus, and remains a threat. A virus found mainly in Southeast Asia called Nipah can cause fatal encephalitis, and can be passed from person to person.
So why does Ebola seem to have the designation as “king” of the scary viruses?
I would argue that it is not merely coincidental that Ebola hails from sub-Saharan Africa. Africa is, of course, a continent with which Europe and North America are inextricably intertwined through the horror of slavery. Might white Westerners be motivated by a collective, subconscious anxiety about the redress of historical wrongs by a lethal virus straight from the heart of Africa?
I don’t mean to reduce the fear of Ebola to an overly simplistic racial equation. But likewise, I think it’s important to understand the racial element of Ebola’s power to instill fear.
Richard Preston, who wrote the first bestseller on Ebola, The Hot Zone, once said that Ebola was “the first act of revenge of the rain forest.” This is perhaps true, but the fear of Ebola could just as easily be read as apprehension of a different type of revenge from Africa, one based on hundreds of years of inhumanity, payback for one of the worst sins humans have ever perpetrated.
Such racial anxieties continue to shape Western policies toward the region.
This is arguably on display in the current outbreak, which has been often treated as a story of minor interest to the world media, in part because of the remoteness of the region.
In July, when three cases of Ebola were detected in the DRC’s neighbour of Uganda, suddenly the outbreak was nearing headline status. Why the sudden interest? Uganda has large, commercial airports. It’s much easier for Ebola to hitch a ride to the rest of the world from Uganda than from the DRC.
In spite of the good news, the dynamics of the current outbreak continue to make Ebola a lurking worldwide menace.
The site of the outbreak is Kivu province, which is the centre of a war zone the size of Alabama. To say that is “politically unstable” is an understatement, and it has been unstable for the better part of two decades. Official pronouncements from the DRC Ministry of Health have been treated with skepticism by armed militias hostile to the central government. Similarly, the good intentions of the international aid groups have been misconstrued, with ETUs being burned and aid workers attacked.
The harder it is for health authorities to do their jobs and eradicate the virus, the longer the outbreak will persist, and the longer the outbreak persists, the more likely it is that an improbable event will occur. Such events might include an infected person catching an international flight.
And once this occurs, the knowledge that there is an effective vaccine as well as effective therapies will likely not provide enough reassurance to stem the tide of panic that will inevitably engulf the region where it appears. For Ebola’s great strength lies not in the absolute number of people it kills, but instead in the chaos it sows. I saw this firsthand in Liberia on repeated visits during the West African outbreak, and I have little doubt that it can reproduce this effect elsewhere, treatment or not.
When the WHO announcement was made on Aug. 12, I happened to be back in Liberia, where I have returned nearly a dozen times since 2015 as part of continuing training of Liberian physicians. The news of effective treatment received a mixed reception. While they were pleased to hear the news, I have little doubt that these Liberian physicians – who had lived through a year of apocalypse, watching friends, colleagues and patients die – must have also been wistful.
It was a week of victory in medicine, although for too many, it came too late.