Saturday, 25 October 2014

Why is Ebola less deadly in America than in Africa?

So far, every story of an American infected with Ebola has ended happily, most recently, with today's news that Dallas nurse Nina Pham — the first patient to contract Ebola in the US — has been discharged from hospital, Ebola-free.

Beating the virus has become a familiar, almost expected, narrative here: Seven out of the eight Ebola patients treated in the United States have survived. These are hugely better outcomes than in Africa, where approximately 70 percent of patients die.It is true that the average West African has a lower life expectancy than the average American. And a much smaller number of Americans have so far contracted, and been treated for, Ebola. But those who have show remarkably good results. "Yes, it’s a small sample size," says Dr. Ashish Jha, director of the Harvard Global Health Institute, adding that there are still "enough data points to say there's something meaningfully different."

This virus didn't change when it arrived in the US. But its medical setting did. Until this year, Ebola was treated in rural and remote areas of some of the poorest countries on earth. Through this epidemic, doctors are learning just how much quick diagnoses, ready access to life-sustaining tools and drugs, and good infection-control practices seem to matter when it comes to a disease that was once believed to be a death sentence.

A stark difference in access to diagnostic tools and drugs

With Ebola, people usually die from multi-system organ failure. One by one, their vital organs shut down because they become so overwhelmed by the fight against the virus.

When that happens, patients get other infections and complications. Their blood pressure drops to dangerously low levels, they become dehydrated and malnourished, their kidneys no longer purify their blood so toxins build up in their bodies. When identified early, modern medicine can easily correct these problems through tools we take for granted in hospitals here: kidney dialysis, IV rehydration, antibiotics.

But you need good diagnostic tools to identify these problems in the first place, says Dr. Joshua Mugele, an American ER doctor with Indiana University who has worked on Ebola patients in Monrovia, Liberia. "If it's a stroke, you want to be able to scan their brain. Or if it's respiratory infection, you want to get a CT scan of their lungs." When he was working in Liberia's capital this year, there was not a single CT scanner in the entire city. 

He also had access to a fraction of the drugs doctors in the US have. And we're not talking about those sought-after experimental Ebola treatments — we're talking about the most basic medication.

For example, in a typical US hospital, a doctor would have at least a dozen different blood pressure medicine that he or she could choose from, depending on a patient's profile and other underlying health issues. This is important with Ebola because severe infection often leads to low blood-pressure, as patients lose bodily fluid, and their organs don't get the blood, oxygen and nutrients necessary to keep going.

Treating these basic problems proved difficult in Monrovia. "In the hospital there, we only had one medication for blood pressure that we could use," Mugele says. "And so if you needed more than that medication, you didn't have it."

A stark difference in staffing

They also didn't have adequate staffing — which is crucial with Ebola patients whose bodies need constant care and attention. In a presentation at an infectious diseases conference this year, the doctors who worked on the American Ebola patients at Emory University in Atlanta pointed out "intensive one to one nursing care was necessary around the clock." That patients were monitored "continuously and this level of nursing care allowed for rapid response to clinical changes" was a matter of life or death.

This kind of 24/7 access is simply impossible in West Africa. Consider the fact that there are 245 doctors per 100,000 US population. In Liberia, the number is 1.4; in Sierra Leone, it's 2.2; and in Guinea, it's 10.

These doctors are also working on patients in unsafe environments, where infection can spread more easily. In Monrovia said Mugele, "We had one nurse tell us she would carry around five pairs of gloves with her. She'd only use those five because she couldn't get more, so she had to decide which patients she would use the gloves on and which she would just wash her hands for."

When health professionals need to ration even the most basic resources like gloves, not only do their own chances of getting sick rise dramatically, but they might infect their patients with other bacteria and viruses circulating in the hospital. These infections weaken patients' already struggling systems, and heighten their chances of death.

In the US, there are also strict protocols for the use of intravenous to rehydrate patients. In Africa, again, these practices aren't always hygienic or tools like an IV drip might not be available for a patient when it's most needed.


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