6. Challenges in the Management of the West African Ebola Outbreak

The mention of Ebola prompts thoughts of the archetypal biohazard and difficulty in managing patients with Ebola virus disease (EVD). However, just as difficult to manage are the outbreaks themselves, and this has been true since the discovery of the virus nearly 40 years ago. Past outbreaks have presented a host of difficulties, and many of the challenges of the past were present once more in the recent West African outbreak. However, new problems have arisen that not only present their own challenges, but are synergistic with known past issues. The international public health agencies that have worked in the past to control EVD outbreaks went into this outbreak prepared to deal with the known challenges and work on an outbreak that was of a scale comparable to what has been seen before. The West African outbreak presented challenges we were not prepared for that forced us to scale up, adapt, and respond.

Logistical Challenges in Responding to an Ebola Virus Disease Outbreak

EVD outbreak interventions have always been complex. To respond comprehensively, the international community, in conjunction with local partners, must put into place a wide array of services. To prevent the occurrence of new cases of EVD in areas where confirmed cases have been found, every situation where further transmission might occur needs to be brought under control. To do so, we first need to find people who are infected with Ebola. When these people are alive but sick, we need to transport them safely to a place where they can be cared for safely. When they have already died of the disease, we need to ensure that they are buried safely. When they are infected with the virus but not yet sick, surveillance systems must be put into place to detect these cases as soon as they become ill. Where we have found cases, we need to decontaminate their environment. In communities where Ebola is being transmitted, we engage in health promotion activities to stop behaviors that cause people to become infected. In health care settings, we must reinforce, or sometimes set up where not existent, infection-control procedures to prevent the infection of health care workers or cross-infection of patients who do not yet have EVD. This allows us to safely treat non-Ebola illnesses while remaining vigilant for cases of EVD that might present to these health care settings. While all of this is occurring, epidemiologists are carrying out investigation of the outbreak to determine chains of transmission; anthropologists are studying community beliefs and behaviors that contribute to disease transmission; psychologists are providing mental health support for patients and their families; and special medical services are set up for convalescent EVD patients.

All of these activities are necessary, and if one is absent or underperforming, control of the outbreak suffers. If EVD survivors are not well cared for, new patients will have a disincentive to be identified and brought to the Ebola treatment unit. If the care provided in the treatment units is not humane and of good quality, the word will get out, and patients in the community will have another reason not to be identified. If the anthropologists do not provide insight into local burial traditions and identify areas of compromise so that they may be performed safely while still respecting important rituals, the community will reject the service offered by the burial teams and disease transmission will go on unchecked. Physicians evaluating new arrivals to the Ebola treatment units to determine whether they should be admitted are dependent on the work of the epidemiologists to describe the chains of transmission and risk patterns to make their decision. This interdependency is why a comprehensive set of activities needs to be put into place to control an outbreak.

The Challenge of Geography

Implementing all of the necessary outbreak-control activities in a single location is already manpower-intensive. In each new location where EVD appears, all of the services need to be duplicated if the outbreak is to be controlled. Prior to the West African EVD outbreak, the number of experienced people in the world who could competently launch and supervise these activities was sufficient for one or two instances of a full outbreak-control apparatus. When the outbreak spread from southeastern Guinea to the capital of Conakry, and then to Liberia and Sierra Leone within the first month, four simultaneous outbreak-control operations had to be put into place. In the first month of the outbreak, the available resources were already overstretched.

As each new location drew upon increasingly limited resources, the experienced staff available to respond to the next location rapidly diminished. When the government of Liberia reported cases of Ebola in Monrovia in June of 2014, few experienced people were available to assist the Ministry of Health and Social Welfare when they faced what turned out to be the outbreak’s greatest explosion of cases in a single location. The weak support the international community was able to provide to this response may have contributed to the magnitude of the outbreak in Monrovia.

Over the course of the outbreak, dozens of locations across West Africa would require their own outbreak-control activities. The international community responded as quickly as it could, and over the course of the epidemic, thousands of people were trained to carry out various Ebola-control activities. It would be hard to imagine how we might have gone into the West African outbreak with more experienced staff, as EVD was rare and few organizations had interest in maintaining competence to deal with it. However, we might have scaled up sooner, as it was apparent even in that first month that we would be coming up short in the face of what lay ahead. It is not obvious how this might have been done, though. Requests for other organizations to get involved were made repeatedly in the early months of the outbreak,1^,2 but few responded.

A Mobile Population

Scaling up to meet the demands of the unforeseen extension of the outbreak does not address the reason why this was a problem in the first place. Perhaps the most important novelty of the West African Ebola outbreak, and one hallmark which distinguished it from all previous outbreaks, was the mobility of the population.3 This was the cause of the multiple outbreak metastases that proved to be problematic. Although there had been a small degree of fragmentation of some outbreaks in the past,4 these had only required control operations to be launched in one or two other locations. Never before had such dispersal of cases occurred. This mobility appears to be the result of the spatial dispersion of friends and family in West Africa, coupled with a transportation infrastructure sufficient to move people about at a cost within the means of much of the population. This made the routine movement of people across several hundreds of kilometers a routine event even before the EVD epidemic. Once people harboring the virus started making similar voyages, cases began to show up in locations well removed from the previously known cases, each requiring yet another set of outbreak-control activities. The resulting strain on resources, most significantly on experienced human resources, was an important factor in allowing the West African outbreak to expand as it did.

Beyond simply taxing resources, the mobile population also posed a challenge for outbreak-control measures as traditionally practiced. When an outbreak is confined to a single region, local teams can keep track of chains of transmission and trace contacts. When cases and contacts move to villages or cities outside the radius of outbreak-control operations, contact is broken. Maintaining surveillance would require knowing the destination of departing cases and contacts and preparing the health authorities there to receive a handoff of responsibility for their follow-up. This was not possible during this outbreak.

A destructive complement to the novel mobility of the affected population was the old problem of our inability to recruit the local population as a partner in outbreak control. We ask people to trust that we have their well-being in mind when we ask the sick to come to the Ebola treatment unit, or when we ask their contacts to allow us to invade their privacy every day for three weeks to see if they become ill or not. If we cannot gain their trust, then our ability to control the outbreak is severely compromised. The fear of Ebola and mistrust of strangers once more in West Africa derailed our attempts to bring the outbreak under control.5 Patients and their contacts hid, and scared communities let surveillance teams know they were unwelcome. Frightened populations that are also mobile have the option to flee as well, and to go quite some distance when they do.

The naïve response to the problem of a mobile population was to impose restrictions on the movement of people. Several times the governments of West Africa experimented with quarantines, border closures, or “lock-downs.” These were of limited effectiveness for several reasons. First, Ebola had usually spread outside of the zones of restriction before the measures were imposed. Second, local communities are often quite adept at circumventing check points and border closures in the parts of the country they inhabit. Finally, oppressive measures are usually counterproductive, as they provide incentive for people to hide from surveillance systems if they think their detection will limit their freedom of movement or that of their family.

In the future, the most effective means of coping with population movement will be to engage individuals’ self-interest in remaining close at hand by providing effective medical services. If an effective therapeutic agent becomes licensed for use, its availability in a treatment center will provide a strong reason for a patient or a contact to remain close by. For those cases and contacts that feel the need to move anyway, the availability of a treatment may provide an incentive for them to maintain contact with health authorities. Outbreak-control agencies will still need to develop a means of handover of surveillance for moving cases and contacts.

Risks to Health Care Workers

Despite the difficulties in gaining the trust of the population and carrying out epidemiologic surveillance, patients were nevertheless brought to the treatment units, where another problem awaited: caring for them safely. The iconic image of an EVD outbreak is that of health care workers dressed in their protective gear. The need to protect doctors, nurses, and others working in proximity to Ebola patients has been a feature of outbreak management for decades. It has also been a limitation of their ability to work for just as long. Any material that provides protection from infectious fluids will necessarily reduce evaporative cooling of the body by perspiration. The current configuration of protective clothing can be endured by most people working in the West African environment for about 40 to 60 minutes. Beyond this time limit, the wearer risks heat illness, impaired situational awareness and judgment, and problems with postural stability.6 At this point, the protective gear becomes a greater liability than it is an asset.

Because of this, a worker no longer represents 8 to 10 man-hours of labor per shift, but rather is limited to 2 to 3 hours of patient contact time. This limitation was more manageable in past outbreaks when the numbers of patients were much lower. The West African outbreak has had more than 50 times the number of cases of the next-largest outbreak on record. More of a problem was the rate at which the number of cases increased, going from less than a hundred new cases per week in July of 2014 to nearly one thousand per week in September of the same year. The demand for care exceeded the ability of the Ebola treatment units to provide it. This disconnect between case incidence and care available led to highly publicized incidents, including the temporary closure to new admissions of the Médecins Sans Frontières facility in Monrovia in September of 2014, and the suspension of intravenous fluid administration until staffing could be suitably expanded.

In the future, if an effective vaccine can provide health care workers with protection, they may be able to wear protective gear that is a good deal more gas-permeable and allows for normal body cooling, and there is reason to believe this is likely.7 Furthermore, changes that have already been made to the design of Ebola treatment units, such as placement of the entrance to single-patient rooms next to high-risk/low-risk barriers or construction of low-risk corridors with plexiglass walls into larger patient tents, allow limited access to patients from outside of the high-risk zone, so health care workers without protective gear can interact with their patients and carry out some of their patient care tasks unencumbered.

Managerial Limitations

The scale and extension of the outbreak forced into service a great number of people who had no prior experience with Ebola. One of the weaknesses this exposed was the extent to which doctors can be successfully employed as managers. Outbreak-control activities require the coordination and supervision of large numbers of people, many of whom are new to the tasks they are carrying out. An effective manager of Ebola outbreak-control activities needs to determine what is necessary to take care of the current accumulation of tasks as well as the backlog of unaddressed work; to plan a service with sufficient capacity to discharge this work in a timely manner; to request the necessary resources; and to oversee the implementation and running of this service. Medical school does not usually teach these skills. Nevertheless, doctors and epidemiologists are often given responsibility for the management of outbreak-control operations that employ hundreds of people.

For example, contact tracing requires that each person who was in contact with someone ill with Ebola prior to their being taken to the treatment unit be visited each day for twenty-one days from the last contact with the infected individual. A manager of a contact-tracing system needs to be sure that their staff is well trained, has the means to communicate back what they find while they are working, has transportation to allow them to visit each of their contacts, and has sufficient gloves and protection material to safely interact with the contacts they are examining. The manager must be able to review the results of what their teams found each day and be able to motivate them to improve their coverage where gaps are identified. Usually, each case will have 10 to 15 contacts. In a location where one has hundreds of cases, there will be thousands of contacts. Visiting each of these contacts every day requires hundreds of people. Managing contact tracing does not require medical or public health knowledge; it requires excellent organizational and human resource management skills. A doctor may have these by chance. A skilled manager has them by definition. Making managers responsible for the supervision of outbreak-control activities would address the most significant deficiency in this activity.

Contact tracing is but one of the many outbreak-control activities. Each activity needs to be well managed to achieve its objectives. The ensemble of all the interdependent activities is a complex whole which itself needs to be well coordinated. Here again, often at the head of the table at a coordination meeting, we almost always find someone whose professional training has been in medicine and whose experience has not been in coordination of outbreak control, let alone with EVD. Historically, the mandate for outbreak control has been either with persons representing the local ministry of health or with the World Health Organization (WHO). Very rarely in the past have outbreaks been well coordinated by either of these organizations. Past outbreaks have ended despite the coordination of outbreak control rather than because of it. The West African outbreak was no exception.

The managerial shortcomings of the various ministries of health in regard to the coordination of an Ebola response are understandable. They have little experience with EVD, and the West African countries had none. The management skills they need for their usual work can be acquired on the job with ad hoc training where necessary. Management of EVD outbreak-control activities is outside the scope of their normal work. On the other hand, the WHO has been involved in every EVD outbreak since the discovery of the virus, and their mandate is to provide support to the member states in matters such as coordination of outbreak control.

A Failure of International Leadership

Outbreak-control activities are ideally carried out by agencies that are able to do so competently. This does not always occur, but for most outbreak-control activities, experienced external agencies are asked by the local ministry of health to carry out outbreak-control activities because of special skills they possess. Field labs from the Centers for Disease Control and Prevention (CDC) or the Public Health Agency of Canada are given the role of testing blood specimens of suspect patients. Médecins Sans Frontières (MSF) is given responsibility for the care of patients. Epidemiologists from CDC, MSF, WHO, and Epicentre, a satellite agency of MSF dedicated to field epidemiology, carry out outbreak investigation. One would think that an experienced coordinator from WHO would take on the coordination of outbreak control. This, however, almost never happens.

To some extent, this problem stems from the WHO’s structure. Article 51 of the WHO’s constitution places the authority to respond to the needs of their member states in the hands of the regional offices,8 which for West Africa is WHO’s African Regional Office. However, the part of the WHO that maintains experience with EVD is part of the WHO headquarters in Geneva, Switzerland. Authority and competence are housed in two separate parts of the organization, which have yet to find a way to bridge this divide. The importance of good coordination, and its absence in past outbreaks, has been a well-understood problem for long enough that the failure of the WHO to resolve this issue prior to the West African outbreak makes it one of the more regrettable aspects of this epidemic.9 Fixing this would take us a long way toward a better response to the next outbreak.

There is some hope that WHO may undertake some of the steps needed to address its problems. An independent expert panel commissioned by WHO to review its response to the EVD outbreak in West Africa noted many of its failings and called for several reforms, including structural ones, noting, “in a Public Health Emergency of International Concern (PHEIC), and possibly in Grade 2 emergencies at the discretion of the Director-General, the reporting lines should switch [away from reporting to the Regional Office]. The regional emergency team and the head of the emergency operation in a country would report directly to the Head of the WHO Centre.”10 It remains to be seen how the WHO will respond.

We went into the West African Ebola outbreak with the same outbreak-control techniques, the same institutions, and, for the most part, with the same people as we went into past outbreaks. In the words of Sean Connery, we brought a knife to a gunfight. As a result, our strengths were out-matched and our weaknesses exposed. The international community scaled up in response. It will be important to go into the next epidemic, not ready to fight the previous war, but instead to apply lessons learned from this outbreak, capitalize on new partnerships, and hold institutions to promises of funding and cooperation.