Managing Epidemics

Keeping oneself informed on national and international health questions has become today a duty. Beyond the technical basics of the Ebola virus that everyone must be acquainted with – origin, classification, transmission, clinical manifestations, laboratory diagnosis, prevention and treatment – I would like to bring some attention to two remaining aspects of Ebola: the anthropological understanding, or its lack, and the actual risks of an entry in India.

I must start by emphasising on one neglected point in the actual fight against today’s most virulent virus. It is a concern that has become for me the most urgent, stemming from my work and experience, as a medical doctor and virologist first, and second, as a citizen of Congo, former Zaire, where the Ebola virus was first discovered in 1976. This is, indeed, the question of the ‘human side’ of the disease.

Since the discovery of the Ebola Virus (EBV) in 1976, simultaneously in the Democratic Republic of Congo (DRC) and in Sudan, the world has been challenged by 26 outbreaks of the virus, and the highest number in a single country, 7, took place in DRC. All the outbreaks have put the local population at the centre of the fight… until this one in West Africa.

This year, the EBV found yet another catalyser: the local culture. In the village of Womey in Guinea, for instance, the population has been suffering from social stigma for many years, as they are forest dwellers. So, when the Ebola outbreak occurred, it was seen by the people of Womey as a premeditated coup attempting to exterminate them. Logically, they did not cooperate with health authorities on disease control or prevention measures. The key to overcome Ebola, beyond the immediate rescue of international institutions, is to educate the people about the disease – telling them how it is transmitted, and how it can be prevented. In those parts of the world, such an education passes through the local people themselves, such as the community leaders, or in the churches, etc. Only this way can the population appropriate the problem for itself. In the West Africa outbreak, this point was not integrated, and it has been the most conducive aspect for the disease.

In contrast, in DRC, the disease is under control. It is restricted only to one district: Boende. In fact, last year, on 17 August 2013, the same happened in the Province Orientale of DRC, but it was not advertised like the current outbreak: it was well managed and controlled. If the world really wants to overcome this unprecedented mortal Ebola outbreak, the same recipe must be followed. But a number of local communities continue thinking that international partners have come to invade them, as they are not informed about what is going on in their land. Some are asking why the American administration is sending soldiers instead of doctors…

But beyond the point on education, the backdrop of culture remains indeed the most important component in tackling such a health issue. We must look at the traditions and cultures of Africa in general, and West Africa in particular. As we all know, the main reservoirs of the virus are bats, monkeys, and chimpanzees, in the form of bush meat. These have been very appreciated kinds of food in most of the African countries, for centuries. Suddenly, scientists, without enough cultural and dietary understanding, request entire populations to stop eating monkeys. It is an unrealistic option for communities that have gotten used to eating this meat for so long. For them, arguing that the monkeys are the source of EBV mortality is a lie. In fact, they stick to their knowledge that not all monkeys and bats are reservoirs for the Ebola virus, but only infected ones. And they want to believe the infected ones are not the ones they eat.

Other cultural practices come on the way to the health requirements of international institutions. In Africa, during a funeral, the dead body must be washed, and relatives touch it. We know that Ebola is transmitted through body fluids, and it certainly happens in those moments of close contact with an infected person. But what can we offer those millions of people, if we tell them they have to stop their traditions? For all of these matters, what is necessary today is not only more doctors, but, more specifically, medical anthropologists. Only this will make a difference, allowing the information to be given in the right way.

And this is without mentioning that the very current medical decisions of those institutions are often very contestable. In many places, the local medical staffs infected died without any etiological treatment, while the western healthcare providers infected in the same areas were cured through experimental vaccines in the USA. This kind of discriminative approach is all but helping the cause: people think Ebola is a manmade fabrication. The overall approach of the medical bodies must be rethought.

Another question very much discussed today in India concerns the risks of the entry of Ebola in the country. An epidemiological analysis can be attempted. The Indian population of West Africa is relatively limited. 4,700 Indians stay in Guinea, Liberia and Sierra Leone. But there are also 40,000 Indians in Nigeria. Several thousands of Indian troops are deployed over other African nations, but away from infected zones. Inversely, estimations amount to around 10,000 Nigerians in India, and we can approximate the presence of Guineans, Liberians and Sierra Leonese to a few thousands.

These figures indicate that the risk for the Ebola virus to reach India is rather low, but indeed still there. With viruses, it is always better to prevent than to cure… The Government of India already implemented health policies to reduce the contamination among Indian troops abroad, and it settled active surveillance to all entry points in the country. But beyond these measures, information and education of the people will remain the key of success against Ebola.

New pathogens have been increasingly emerging during the last few decades, due to the combination of an incredible complexity of factors: globalisation, unprecedented growth and expansion of human population, environmental changes, global warming, industrialisation and changes in farming systems, deforestation, extension of agricultural land and mining area, unplanned and uncontrolled urbanisation, increased human-animal interface, microbiological adaptation… Hence, no country or part of a country can afford to treat any new disease lightly, as it has the capacity to cause an alarming public health concern. Then, indeed, any of the northeastern states, including Mizoram, would do well to prepare for any threat arising from any part of the world. As the Ebola Virus Disease (EVD) outbreaks currently taking place in western Africa are claiming more and more lives on daily basis, the World Health Organization has requested its member countries to take precautionary measures. In response to the request, the Government of India has subsequently prepared guidelines and issued instructions on how to deal with the current global threat of Ebola.

Before touching the Ebola related issues concerning the state of Mizoram, it may be proper to give a brief account of the state. Being the remotest part of the country, bordering Myanmar in the East and South and Bangladesh in the West, Mizoram occupies an area of great strategic importance in the North Eastern corner of India, having 722 kilometres of international boundary. The state is full of variegated hilly terrains, steep and separated by rivers. The average height of the hills is about 1000 meters. Mizoram has a moderate climate with temperature varying from 10° to 30° C. The state receives a long rainy season from May to September and the average rainfall is 208 centimetres.

In Mizoram, education is happening satisfactorily, so health measures are well received by the population. A radio live phone-in programme conducted by the author and colleague Mr Lalfakzuala has indicated that the people, being largely literate, are well aware of what is happening in western Africa. The recent H1N1 pandemic and the activities on prevention and control, case management and screening of travellers at strategic points have made an impact on the population on a large scale. The state population is seemingly confident in the state machinery dealing with the disease in case it strikes in any zone.

On the other hand, the health authorities of the state, including the Chief Minister and Health Minister and their subordinates, have been playing prominent roles and remain actively involved. This is indicated by the fact that those dignitaries have participated in meetings where the Chief Secretary and the Secretary of Health & Family Welfare Department issued a list of actions to be taken by the department and allied departments towards the prevention and containment of Ebola cases, if any arises.

Accordingly, actions have been taken on dissemination of information and documents received from the Government of India to doctors in Government and Private Hospitals through download on the Department website. Technology can be of a great help in such contexts. Compliance to the guidelines laid down in the documents is made mandatory and the hospitals shall abide by them without fail for prevention and containment, sample collection, transport, etc. in case the outbreak strikes the state.

The general public is also made aware on the EVD through radio live phone – in broadcasts such as Doordharsan’s Healthy India Programme. Education material has been prepared in Mizo for dissemination and publicity, as and when required. However, it is felt that it may be too early to undertake the screening of passengers at the domestic airport, while incoming passengers at international airports have been undergoing mandatory screening, particularly when coming from Africa. The stock of PPE (Personal Protective Equipment) in the Department of Animal Husbandry & Veterinary, unused during the H1N1 pandemic, is reserved for any untoward event. Hospitals specialising in the treatment of Ebola cases are already identified for use, if any case arises.

The state has identified a Nodal Officer who shall also act as a Spokesman on issues concerned with EVD outbreak in the state. He shall be responsible for the smooth flow of information to the higher authorities in the State and the Government of India. The high level meetings have contributed to the constitution of a rapid response with team members identified by designations instead of being individually identifying at state and district levels. The objective is to avoid repeated issue of Government notifications.

The state has been receiving excellent rapport from the Centre, which is alert enough to give first-hand information on Ebola. In fact, the Government of Mizoram has had full support even during the H1N1 pandemic, and it handled the cases satisfactorily, with a final amount of one death – a case that had gotten infected from outside. In spite of this, the major challenge lying ahead of the state is, as in the case of any disease having potential for causing public health threat, the porous long international borders with a relatively established cross-border illegal trade. The cases can go undetected and spread to the communities before actual intervention takes place. Authorities must remain attentive and ready to intervene. Hence, the need for continuing the creation of alertness among public in general and the healthcare providers of the state in particular is the primordial direction to tackle the possible entry of Ebola in India.