In a paper released Wednesday afternoon titled Ebola Then and Now, two doctors on the frontlines of the 1976 outbreak in Zaire recall the meticulous procedures that kept the climax of the outbreak to 318 people. While the piece offers valuable information for those fighting the current Ebola outbreak, it underscores just how dangerous it has become. That was then, this is now. Here, juxtaposed with the New England Journal of Medicine’s report, is today’s response.
1. Delayed Response Time
The study’s authors, Dr. Joel G. Breman and Karl M. Johnson, arrived in Zaire in 1976 equipped with new virologic and immunologic tests that helped them immediately identify the (then new) agent. “In Zaire, we became, respectively, the chief of surveillance, epidemiology, and control and the scientific director of the International Commission for the Investigation and Control of Ebola Hemorrhagic Fever in Zaire,” they write. Immediately upon arrival, five commission members were sent to the village of Yambuku—the original site of the outbreak—to map the extent of the outbreak. The other 70 members remained at the hospital base.
On March 23, 2014, the World Health Organization (WHO) reported what they called a “rapidly evolving outbreak” of Ebola in West Africa, where 49 cases and 39 deaths had been recorded. One month later, the number of cases had quadrupled, with WHO showing more than 208 cases and 130 deaths. It wasn’t until August 6, with 1,779 cases and close to 1,000 deaths, that WHO began discussing whether or not the outbreak constituted an international health emergency. By the time it did a few days later, which made it nearly six months after the initial outbreak, it was too late.
2. Infective Quarantine
When Breman and Johnson arrived on the scene, the government had already quarantined 275,000 people in the Bumba Zone. Planes, boats, cars, strangers—all were banned from entering the cordoned off area. At first, the doctors write, the villagers were “fearful and agitated,” lacking the basic necessities needed to survive. When members of the International Commission arrived to help, the community was wary. But with an electron micgrograph to illustrate what was fueling the outbreak, they were able to gain the trust of the people. “People along the road from the town …were relieved when we said we’d come to stop the disease’s spread, treat patients, and meet their families,” the paper reads. Inside the quarantine zone, even more specific procedures were outlined to keep those within the bounds of it safe.
Attempts to quarantine during the current outbreak, led by the local armies and police, have been catastrophic. When the Liberian government attempted to contain the outbreak in Liberia through a quarantine in West Point—an exceptionally impoverished area near Monrovia—they did the opposite. With anywhere from 70K to 120K residents living in tiny shacks without running water, sanitation, or electricity, they left a struggling demographic without the means to protect themselves—many, without knowledge of what it was that necessitated protection. With people fighting for food, violent outbreaks between Liberians and the army began to heat up at the 10-day mark. When four were injured and one killed, President Ellen Johnson Sirleaf officially lifted the quarantine.
3. Mistrust from Communities
For those outside of the quarantine zones, Drs. Breman and Johnson laid out specific guidelines to community members to help reduce the risk of the infection’s spread. Family members who became infected with the disease were placed in “huts outside their villages,” a procedure that allowed victims to be isolated outside of a hospital. The doctors then suggested one family member, “preferably someone who had recovered from the illness,” deliver food, water, and medicine to the patient each day until a medical professional could arrive on the scene. With the help of other community members, the doctors successfully educated the families of those who died about the dangers of handling the body in typical ritual fashion. “Credibility was gradually restored,” the authors write. “Especially when we began visiting villages accompanied by the three remaining nuns.” Bodies were covered with bleach and buried, and isolation huts burned. An already-local tradition of shaving one’s head in mourning for a lost family member became dual purpose—used to flag potential carriers of the disease.
With the virus already widespread when international relief began pouring into West Africa, spending individual time in affected communities was not an option. Without this crucial period of trust building, many in the communities spent months under the impression that Ebola was either a hoax or a disease brought to West Africa by American nurses and doctors. The fallout of this loss of trust has had an enormous impact on the outbreak. Without a clear understanding of how Ebola is spread and when it is contagious, family members continued to bury their loved ones—who, at that point, are the most contagious—with typical burial rites such as washing, touching, and even kissing the corpses. While doctors in West Africa now report success educating the communities and persuading them not to perform burials, the amount of burials already performed have infected hundreds if not thousands.
At the end of the report, which highlights stirring images from the original 1976 outbreak, the authors offer suggestions for where the international community should focus their support. “We believe the main priorities should be adequate staff for rigorous identification, surveillance, and care of patients and primary contacts,” they write. “Strict isolation of patients; good clinical care; and rapid, culturally sensitive disposal of infectious cadavers.”
Breman, who got wind of the current outbreak when a CDC officer stationed in Guinea called him for advice in March, is still optimistic. Most of his positivity rests on the news that people in the villages have finally begun to trust that the outbreak is real, and that the health workers are there to stop it. And with the announcement that the U.S. plans to send a “surge” of workers into West Africa armed with $22 million from the Pentagon, America now looks poised to fight back against Ebola.
“These are the darkest days, they know what they’re doing,” Breman tells me of the health care workers in the field. “They know the dangers. There are dangers at the front lines. It’s a war zone, and Ebola is the enemy.”