Why Ebola Epidemic Won’t Become the ‘Black Death’

The ongoing outbreak of Ebola in a three-country region of West Africa is the worst that mankind has ever seen.

The latest assessment estimated that more than 5,800 people have been infected and 2,803 people have died, but many health officials warn the toll could be much higher.

At its current infection rate, the World Health Organization (WHO) estimates 20,000 Ebola cases by November in a study published in the New England Journal of Medicine today. Now that the infections have moved from largely rural areas to densely populated cities, some projections show many more infections by the end of September.

The U.S. Centers for Disease Control and Prevention (CDC) revealed a new report Tuesday that states that without additional intervention, Ebola infections in Nigeria and Sierra Leone could reach 21,000 cases by the end of the month. That rate is expected to double every 20 days.

“If conditions continue without scale-up of interventions, cases will continue to double approximately every 20 days, and the number of cases in West Africa will rapidly reach extraordinary levels. However, the findings also indicate that the epidemic can be controlled,” the report concludes.

In the beginning, people thought this outbreak would be the same way it has been in the last 40 years. It became painfully evident that this outbreak wasn’t going to be controlled quickly.
Dr. Amesh Adalja

A large hurdle in determining the virus’ true impact is overcoming many people’s resistance to reporting infected patients. There have been numerous reports of people hiding the bodies of the infected because of fear and distrust of authorities there.

That distrust and several other factors have created a perfect storm for a disease epidemic in Liberia, Guinea, and Sierra Leone, an area also affected by other diseases fueled by a lack of basic medical care and resources. 

Dr. Amesh Adalja, an infectious diseases expert and member of the Infectious Diseases Society of America’s public health committee, told Healthline that the epidemic festered early due to a lack of medical infrastructure and other problems. 

“In the beginning, people thought this outbreak would be the same way it has been in the last 40 years,” he said. “It became painfully evident that this outbreak wasn’t going to be controlled quickly.” 

In response, the WHO, the U.S. military, and other organizations have mobilized for the largest outbreak response in history.

“This unprecedented outbreak requires an unprecedented response,” Dr. David Nabarro, the U.N. Secretary General’s Senior Coordinator for the Ebola Response, said in a statement. “The number of cases have doubled in these countries in the last three weeks. To get in front of this, the response must be increased 20-fold from where it is today.”

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Poverty and Distrust Fuel Epidemic

Years of civil war in Sierra Leone and Liberia, which only ended a little over a decade ago, destroyed much of the area’s infrastructure and crippled their economies. This left many of their citizens living in dire poverty.

Coupled with a history of extensive political and government corruption, a large portion of the citizens in West Africa have a distrust of authority, whether government or relief workers. A large contributor to the spread of the disease, experts say, is fear. People fear going to the hospital as they are centers of outbreaks, and they fear workers in protective suits spraying disinfectants in their communities.

“People don’t trust the government there,” Adalja said.

Last week, the bodies of eight people — health workers and journalists — were found days after they were attacked in a small village in Guinea. The group was attacked by “angry and fearful” residents while they were trying to disinfect the area and educate people about Ebola, The Washington Post reported. Previously, quarantine camps in Monrovia, Liberia’s capital city, were attacked by civilians, leading to the infected fleeing and exposing others to blood and bodily fluids.

Those attacks are anything but isolated, however. Reports of violence have been widely reported across West Africa. Many residents believe the people doing the disinfecting are actually poisoning the population. An alarming subset of the population doesn’t believe the Ebola virus is real.

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Villagers in Gueckedou, the town at the heart of the Guinean Ebola epidemic. Photo courtesy of the European Commission's Humanitarian Aid and Civil Protection Department/ECHO.

The violence, unrest, and distrust are only making efforts to treat the infected and prevent the spread of disease that much more challenging.

Dr. Kent Brantly, an American medical missionary infected with Ebola while in Liberia and treated in Atlanta, recently testified before Congress, calling the medical capabilities of the region “woefully inadequate.” His was the only facility in southern Liberia that had set up an Ebola treatment center.

“The disease was spiraling out of control and it was clear we were not equipped effectively on our own,” he told Congress. “We began to call for more international assistance, but our pleas appeared to fall on deaf ears.”

Brantly described the fear of being isolated, unaware if he’d ever see his family again, and fearing vomiting blood, a sure sign of the internal bleeding that could have lead to his imminent death. Others who have been infected have taken it upon themselves to be treated at home, which spreads the disease to caregivers and others.

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“It is a fire. It is a fire from the pit of hell,” Brantly said.

Within days, President Barack Obama deployed 3,000 U.S. military personnel to West Africa. Their goal is to build 17 medical facilities with 100 beds each, train 500 healthcare workers, and coordinate international relief efforts.

The international intervention, spearheaded by U.S. forces, is tasked with expanding the three nations’ medical infrastructure to provide at least basic medical technology.

“We know that Ebola is stopped with very low-tech interventions.” Adalja said.  “But they really don’t have the space or capacity to take care of infected people.”

For example, the civil unrest left Liberia with only one doctor and 27 nurses per 100,000 people as of 2008, according to the WHO

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Basic Interventions Have Large Impact

Unlike other strains of Ebola in which infection is fatal in 90 percent of cases, the strain currently spreading through West Africa is fatal in just over half of the cases. Relief workers are finding that basic medical interventions — quarantine zones, disinfectants, and protective clothing — are the best defense in controlling the spread of the virus.

The CDC worst-case assessment suggests that if 70 percent of known infected patients were isolated in either quarantine or in a community setting with reduced risk for disease transmission — including safely burying the dead — the epidemic would be nearly over by Jan. 20.

Ebola won’t be a threat to Americans. It will not find the U.S. to be a hospitable place.
Dr. Amesh Adalja

During a three-day border lockdown in Sierra Leone last week, 130 new cases were discovered. Isolation practices have slowed the outbreak in Nigeria and appear to have stopped it entirely in Senegal. 

As Ebola is spread through direct contact with bodily fluids, it is easy to prevent a severe outbreak, if safety standards are met. In West Africa, people at hospitals where Ebola-infected patients were present routinely shared oral thermometers without disinfectant between patients.

“That’s not something that would ever really happen in the U.S.” Adalja said. “Ebola won’t be a threat to Americans. It will not find the U.S. to be a hospitable place.”

There has yet to be an Ebola-related death on U.S. soil. 

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With screening, contamination, and basic safety practices, other countries have been able to keep passengers traveling from West Africa from potentially spreading to other countries. On Monday, Canadian drugmaker Tekmira Pharmaceuticals announced that it received emergency approval to use its experimental treatment, TKM-Ebola, to treat infected patients.

Why Ebola Won’t Become the Next Plague

Ebola doesn’t have the capacity to spread like measles or tuberculosis, which can be transmitted by breathing the same air as an infected patient. It also doesn’t have the ability to infect a global population like the “Black Death” that killed up to half of Europe’s population in the 14th century.

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Red Cross workers in Guinea. Photo courtesy of the European Commission's Humanitarian Aid and Civil Protection Department/ECHO.

“Ebola hasn’t reached those heights yet, and plagues can be contracted through drops of fluid,” Adalja said. “This is the worst Ebola outbreak, but it’s not going to be something that could spread in the manner of a Black Death. It may be deadly, but it’s not highly contagious.”

However, Africa and other parts of the world continue to battle other deadly diseases besides Ebola. The largest health threats facing low-income countries are fed by unprotected sex, lack of sanitation, and lack of food.

Malaria continues to be a far bigger threat to Africa and to other parts of the world than Ebola. As about 90 percent of the 627,000 malaria deaths in 2012 occurred in Africa, efforts to protect vulnerable people against malaria-infected mosquitos continues to be a major health priority.

HIV continues to be a thriving epidemic across sub-Saharan Africa. While West Africa has the lowest infection rate in the region, the main driver is the prominence of sex workers, unsafe blood transfusions, and mother-to-child transmissions, according to AVERT, an international HIV and AIDS nonprofit. In Nigeria alone, 210,000 people died from AIDS in 2011.

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Western interventions targeting these endemic diseases have helped, but there is still much to be done. Upgrading the medical infrastructure, training doctors and nurses, and educating the public about how disease spreads will not only stop Ebola, but also leave the affected nations better equipped to handle other diseases in the future.