Monday, January 19, 2015

How to stop Ebola

Not a single American victim has died of Ebola; the majority of Europeans infected have survived; a Cuban survivor is already back here at work. Across West Africa, 70 per cent of those afflicted die. And that figure applies only to the sick who receive care at treatment centres: More than 90 per cent of those who stay home perish. What accounts for the extreme variation in death rates? Firstly, it is not that foreign aid workers are shipped home and receive experimental treatments.

What kills most Ebola patients is a massive loss of the body's vital fluids - up to 10 litres of day - along with proteins and electrolytes, primarily through vomiting and diarrhoea. We often hear there's no treatment for Ebola or other hemorrhagic viruses. That's not true. Survivors all received was excellent supportive care, most of it from nurses. In medical parlance, the term "supportive care" does not mean hand-holding but the replacement of fluids and electrolytes; treatment of secondary infections (bacteria escaping from the gut, say, or malaria); and, in some cases, renal dialysis and assisted ventilation.

Three weeks ago, a baby named Jariatu was found by a burial team, barely alive, in a house full of dead family members. She was taken to Port Loko, where nurses and doctors were unable to locate a vein for an IV; the baby was dying, too unresponsive to drink. So they did what they would do in Boston or London: They inserted an infusion needle into the bone marrow of her tibia. It was three days before Jariatu was conscious enough to show any interest in taking anything by mouth. She's expected to survive.
What was always needed to improve survival in West Africa is the capacity to safely deliver excellent supportive care. It's hard to deliver supportive care there, due to the obvious lack of staff and stuff and space, and it's dangerous.

Nevertheless, though they're afraid of Ebola, as any sane person should be, thousands of medical professionals, most of them African, show up for work every day (a lack of electricity makes it hard to make a similar claim about night shifts, which is another cause of high mortality). Could there be a relationship between poor-quality care and people's reluctance to seek it in hot and raggedy Ebola units, where patients are interned until death or until blood tests show no circulating virus?

The quality of care in this part of West Africa - not simply for Ebola but for more common ailments and injuries - must be improved. It means cooler units - even fans would help - and personal protective gear made for tropical conditions. It means improved nutrition and a lot more support for the public health delivery system. Since hospitals with poor infection control have always amplified Ebola's spread, the two tasks - stopping transmission and improving care - are the means by which the world's largest outbreak will be halted and proper health systems built.

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