Putting Patients First to Stop Ebola

Last summer international aid workers began descending from Soviet-era helicopters into the forests, mountains and villages in the Democratic Republic of Congo’s North Kivu region, setting up treatment centers and laboratories, and donning hazmat suits as they treated people sick with the Ebola virus. The workers brought computers, lab equipment, vaccine doses and anything else that supported epidemiology, data and patient management, and infection prevention and control.

And in this particular Ebola outbreak, they also brought helmets and flak jackets, courtesy of the United Nations.

Health workers in Congo have met not only disease but also a complex and often violent sociopolitical environment in communities that have suffered unimaginably for many years, at first from Congo’s civil war that killed more than 5 million people and, in recent decades, from scores of holdover armed militias, locally called Mai-Mai.

Although Daniel Bausch ’83, an expert in tropical and infectious diseases, has worked in many Ebola outbreaks, this situation seems particularly dire. Mai-Mai — intent on extorting money — and victims’ grief-stricken families attacked five Ebola treatment centers in February and March, burning down one and killing two people, causing the humanitarian organization Doctors Without Borders (Médecins Sans Frontières or MSF) to temporarily withdraw its staff.

Violence continued into the spring, when armed men stormed into an Ebola meeting in the town of Butembo and opened fire. They killed Richard Valery Mouzoko Kiboung, an epidemiologist for the World Health Organization (WHO), and injured two other workers.

Since January, more than 85 health workers have been killed or wounded, according to the WHO, and as of June 27 more than 1,430 people had died from Ebola. It has become the second-worst Ebola outbreak in history and the first to take place in a conflict zone. Now Congo and international health officials fear that the Ebola outbreak could spiral out of control unless the violent attacks against health facilities and workers stop.

“It’s an extremely complex and volatile situation, with a fearful population sometimes violently resisting control efforts,” Bausch acknowledges. “We can’t be too judgmental about the people because they have been in this violent, very manipulated situation for a long time. Ebola is often viewed as just another weapon or means of political manipulation.”

Nurturing Local Partners

Bausch has continuously voiced the need to view Ebola and other diseases not only as contagions to be stomped out but also as symptoms of extreme global inequality. He views people living in affected countries as essential partners in treating their compatriots and works to help them live in vastly improved, healthier circumstances with the capacity to address outbreaks on their own.

“Ebola is a scary, fascinating, terrible thing, and I’ve engaged with it directly and indirectly,” he says. “What I and others need to work toward is not only an on-the-ground response — which is obviously super important — but also, where does this come from? Why do we have this disease that seems to afflict only the poorest populations in the world? It’s not random who gets a communicable disease. There are many social, political, environmental and economic factors. Ebola is the canary in the coal mine signaling the world’s most vulnerable populations, people whose human right to health hasn’t been assured.”

The situation in North Kivu is especially complicated because of the region’s abundance of minerals, such as gold, tungsten and uranium, which are highly prized by the global technology and defense industries. Despite such riches, many towns in the area lack centralized electricity and water, internet and paved roads. Because the Congolese government is largely absent, residents rely on NGOs for basic health care and infrastructure.

When Ebola hits, responders try to stem disease transmission by sending out workers who conduct “contact tracing” — investigating suspected cases of Ebola in people’s homes and then tracking down all the people they interacted with in order to get them into isolation and care if they fall sick and vaccinate them. Ideally, investigators would visit all contacts every day for 21 days to check for early symptoms, something that is virtually impossible in the chaos of northeastern Congo today. Yet, every missed diagnosis can result in dozens or hundreds of additional cases.

If the person has already died, helping the family safely prepare the body for burial is crucial. Workers must walk a fine line between respecting cultural customs while also minimizing transmission. Investigators advise family members not to touch or kiss their loved ones, because bodily fluids on dead bodies are laden with the virus. To make matters worse, teams of workers must also decontaminate dwelling places with chlorine. But some property, such as mattresses, needs to be destroyed, which can further alienate the community.

Deep suspicions on the part of the Congolese make sense to Lina Moses, an assistant professor at Tulane University’s School of Public Health and Tropical Medicine, who has worked with Bausch on many outbreaks.

“People in West Africa and the Congo are dying all the time from many different things — starvation, violence, other diseases — and the international community doesn’t seem to care,” she explains. “But then there’s one case of Ebola, and everyone descends on the village. This has bred mistrust of outsiders, even people from [Congo’s capital] Kinshasa. I’ve never seen any response by local communities that seemed to me irrational if you understand the context.”

Although Bausch says the security situation in North Kivu is the most challenging he’s faced, the virologist says he and colleagues have encountered strong community resistance before. And there has also been chilling violence. He points out that in 2003, Congolese villagers beat and stoned to death four teachers who they accused of casting an evil spell to cause an Ebola outbreak.

And then there was the 2013–16 West African outbreak, where the international response was slow and lacked enough resources to battle the virus effectively. At one point in Sierra Leone, Bausch and one other colleague from the WHO, both wearing heavy protective gear in the stifling heat, did their best to manage about 60 patients. By then, all the nurses had died or fled in fear, leaving behind a facility bereft of support. It was, he says, the hardest situation he’s ever been in.

One moment from that time still haunts him. He had walked into an intake room where there were three beds crowded with people who had recently staggered in with symptoms of Ebola. On one mattress, a young girl who looked about 8 years old was already dead.

The only thing that Bausch knew about the girl was that she had come to the treatment center alone, and that broke his heart. He suspected that the rest of her family had already died, and he imagined her excruciating last moments.

“She reminded me of my own daughter, who was the same age at the time,” Bausch recalls. “I thought about all the horror this girl had endured, coming on her own from what must have been a terrifying situation at home to a hospital with such a strange and fearful environment, full of strange white people like myself wearing masks and gowns, and put onto a bed where other people were sick and bleeding.”

Whenever possible, Bausch tries to connect with people on a personal level and is known for being open and friendly with locals and co-workers alike. Nahoko Shindo, a disease expert at the WHO, remembers the first time she worked with Bausch in Sierra Leone and Guinea during an outbreak of Lassa fever. “It was difficult at first to know what to make of him,” she says, laughing. “When I first met him, he was wearing very bright African clothing made by local tailors. That impressed me. He was not your typical American.”

Another colleague, Stuart Nichol, chief of the Viral Special Pathogens Branch at the CDC, recalls Bausch’s remarkable work during a Lassa fever outbreak in Guinea, where he set up a field lab and collected rodents to test for infections, to better understand the transmission of Lassa virus, which is maintained in rodents and sometimes transmitted to humans through rodent consumption. “While he was managing research teams, he was also trapping, freezing and shipping these biospecimens to CDC labs in Atlanta for further analysis,” Nichol says. “And he was trying to get solar panels placed on the lab’s roof to generate more energy. Most clinicians wouldn’t be doing that. He has always been willing to get his hands dirty and do what needed to be done.”