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It’s the biggest outbreak ever of Ebola, affecting more than 1,200 people in three countries — four, if you count the man who traveled to Nigeria and died there. The virus is spreading out of control, according to all the experts involved, and there is no clear end in sight.
The casualties include health care workers on the front lines, most recently an American doctor and a hygienist colleague working for charities, and Dr. Sheik Umar Khan, the doctor leading the fight in Sierra Leone, who died.
So there must be a cast of thousands in there, deploying equipment, medications and vaccines, and dispensing advice, right?
The U.S. Centers for Disease Control and Prevention has sent 12 people. “We currently have 12 staff deployed in Guinea (5), Sierra Leone (1), and Liberia (6) helping to coordinate the response at the national level, providing health education and assisting with database management,” said Dr. Stephan Monroe, deputy director of CDC's National Center for Emerging Zoonotic and Infectious Diseases.
They’re not treating patients — they’re providing advice.
What about the World Health Organization? That’s a big international group. “We have deployed over 120 people so far — our own, plus partner, staff. But we need a lot more,” says Gregory Hartl, a spokesman for WHO in Geneva. Cutbacks in international investment have forced WHO to slash budgets.
The rest is being covered by nonprofits, and the affected countries' health departments, which are not even close to being equipped to handle an outbreak like this.
“This is a nuts outbreak compared to anything I have ever seen,” said Thomas Geisbert of the University of Texas Medical Branch in Galveston. “Geographically it is such a huge area and the virus seems to be popping up like whack-a-mole. The people who are skilled in responding are spread thin.”
It’s a desperate situation by any description. Sierra Leone, Guinea and Liberia are all underdeveloped countries, with little medical infrastructure and with large swaths of countryside that don’t even have roads. Years of poverty and war have left governments in the region with few resources.
In Bo, a large city in Sierra Leone, there are fewer than 15 physicians to cover a population of between 150,000 and 450,000 people, says Kathryn Jacobsen, an epidemiologist at George Mason University in Virginia who recently returned from Bo.
"We need a lot more."
This lack of infrastructure is helping fuel the epidemic. “Hospitals don’t have the supplies to take precautions with every patient that comes in,” Jacobsen told NBC News. To protect themselves from Ebola, health care workers must wear gear called personal protective equipment (PPE) that covers them from head to toe — full body suits, boots, masks, goggles and several layers of gloves. It’s expensive.
“A lot of the health care facilities don’t have the PPE that the clinicians need,” Jacobsen said. “Let’s say someone comes in with a fever. The assumption would be that this is malaria. You test for malaria by taking a little blood out of the finger and you look for the malaria parasite.”
This is a routine procedure, and a very easy way for a health care worker such as a nurse to get what’s called a needle stick. It’s not a big deal with a malaria patient. “But what if it turns out that person has Ebola, and the facility is not equipped for Ebola?” Jacobsen asked. That needle stick could be deadly for the health care worker. Dozens of nurses and doctors have died in this current outbreak, many infected because they didn’t have the gear they needed to protect themselves.
"In Liberia, the situation is deteriorating rapidly, with cases of Ebola virus disease now confirmed in seven counties, including in the capital, Monrovia," Medecins Sans Frontieres (MSF or Doctors Without Borders), which is providing much of the medical care, says in a statement. "There are critical gaps in all aspects of the response, and urgent efforts are needed to scale up, particularly in terms of contact tracing, organizing safe burials, and establishing a functioning alert system."
Like other groups, they're thin on the ground. "Already stretched beyond capacity in Guinea and Sierra Leone, MSF is able to provide only limited technical support to the Liberian Ministry of Health," the group added.
“The outbreak has grown to the point where there is a desperate need for more international intervention,” said Michael Stulman, a spokesman for Catholic Relief Services in Sierra Leone. “Right now it’s being carried on the shoulders of groups like Samaritan’s Purse and MSF in close cooperation with CDC and WHO. But there is a desperate need.”
There’s no specific drug to treat Ebola. The best treatment is saline intravenous solution, along with fever reducers and antibiotics to take care of any secondary infections. Patients need constant supervision to make sure their blood pressure doesn’t crash to deadly levels, and to try to control the vomiting and diarrhea that so weakens them.
They must be isolated, and constant disinfection is vital. It runs the doctors, nurses and technicians ragged, says Dr. William Fischer of the University of North Carolina-Chapel Hill, who’s treated Ebola patients in Gueckedou, Guinea.
“It’s tough to describe what it’s like there, other than to say intense,” Fischer told NBC News. “It’s incredibly taxing both physically and emotionally.”
Stulman said his group was rushing to build new facilities to care for dozens of patients. In Kenema, in Sierra Leone, one hospital is now entirely devoted to 60 Ebola patients, says Dr. Robert Garry, a Tulane University virologist helping to fight the outbreak.
“It’s incredibly taxing both physically and emotionally.”
Garry hand-carried sets of PPE to the Kenema hospital earlier this year, and returned to the U.S. to beg donors for more.
There's the enormous issue of distrust, with patients hiding in the forest rather than submit to health workers they fear may be spreading disease and death. Many of those who might want help cannot even get to treatment facilities.
“One of the biggest barriers to diagnosis for people who think they might have the Ebola virus is the poor road network in the areas currently affected by Ebola,” Jacobsen said. “It is difficult for people living in rural areas to travel to a hospital, and most would have to travel even farther to get to a hospital that is accepting and treating suspected Ebola patients. Most families do not own cars, most rural communities are not connected to bus routes, and private transportation can be quite expensive compared to local incomes.”
And that’s just to help the patients who have been found. “There are major public health gaps in the ability simply to monitor what is going on,” says WHO’s Dr. Keiji Fukuda. “We know in some countries there are no surveillance systems to monitor what is going on.”