When Ebola is the lesser evil

Ebola outbreak

The outbreak begins

The morning after I arrive in Uganda, I wake up to a newspaper being shoved under my door. I can see the headline from the bed. It reads “Ebola Outbreak in Kibaale”, with "Ebola" rendered in two-inch high red letters. Kibaale is a district in Uganda about two hours’ drive from where I'mstaying.

I’m there to work on an innovative project run by a large NGO seeking to harness the ubiquitous, cheap mobile phones that proliferate through poor, rural communities. The project aims to radically enable savings behaviours, community loaning and financial literacy. If you haven’t been to Uganda, you should. It’s beautiful, the wildlife is amazing, and the people are without a doubt one of the friendliest, vibey and energised cultures anywhere. It’s a country with a difficult history, but it’s also a country that has a bright future. At a systemic level though, it is not without challenges.

The next day, a patient with Ebola is in Kampala’s main referral hospital, a few minutes’ walk from my apartment. The numbers of infected patients begins climbing in Kibaale. The city is filled with anxiety, and conversation about the disease nervously plays with rumour the way a child plays with a scab. My parents call me and I spend some time easing their fears. Ebola is a bogeyman, and the news of the outbreak has spread, virus-like, across the world.

The service I’m helping design is about helping the very poor save their money for goals like getting their kids an education, or starting a microbusiness. To really understand the need, we plan to do some field research in villages. I ask one of the local ethnographers if the village we’re going to the next day is near Kibaale. He looks at me like I’m mad, and shakes his head. “Of course not!”

That night on the news, there are images of red stains on white sheets in Kagadi Hospital, near the outbreak’s epicentre. The footage is followed by an interview with the president, who suggests a temporary moratorium on “handshaking and promiscuity”. Ebola is spread by contact with body fluids. Once transmitted, it works its way through the victim’s tissues, causing widespread cellular destruction. In many cases (and depending on the strain involved, that can be as high as 90%), the body runs out of clotting agents so that a needle prick can turn into a fatal wound – sort of an acquired haemophilia. Patients can vomit blood, leak blood from their gastrointestinal tract, their eyeballs can become bloody. Their faces become expressionless. It’s a horribly efficient contagion.

After the news, and by coincidence, the movie Outbreak starts on the television. I switch it off.

Shortages at the ebola epicentre

After a few days, news about shortages at Kagadi hospital begins to surface. The picture resolves into something that is as horrible as the disease. Kigadi hospital is out of fresh personal protective equipment – the barriers that are needed to keep healthcare workers from being infected. Supplies of medicines, medical consumables and equipment are low. Patients and people with suspected cases begin to strike, complaining about the lack of food. The hospital has no money to feed its patients. They are surviving on juice and biscuits. Donations start coming in from private companies, from NGOs like the Red Cross and Medicines Sans Frontiers.

I am amazed by all of this. How does a hospital at the epicentre of an Ebola outbreak run out of food? How do healthcare workers run out of fresh gloves while dealing with a highly communicable haemorrhagic filovirus? It’s unimaginable to me.

The gap between administrative wisdom and service delivery

As I was flying in to Entebbe airport a week or two before, I sat next to a guy who turned out to be a medium-level health official in the public service. We talked about his job, and it turned out that he spent some of his time behind a desk as a policy advisor, and some of his time out in the field understanding the on-the-ground view of healthcare needs and program effectiveness in rural Uganda.

Our conversation jumped from policy design to front-line realities. While his job only spanned these two worlds because of a lack of resources to fund more staff, it seemed like such a fantastic combination of roles. In Australia, we strongly value evidence-based policy and program design. Here was its essence – a policy professional who knew that the challenges were because he just spent a fortnight in the field, walking around amongst them and talking in situ with the affected communities.

In a place where the administration could be so closely exposed to the communities they supported, thinking back to that conversation only heightened my confusion. And not just about the ebola response (which was ultimately very well contained by locals collaborating with a fast international response, the stars of which being the incredible doctors of Medicines Sans Frontiers).

Take Mugalo hospital, the country’s main hospital. How, how could it routinely not have enough blankets for patients? What is going on in Uganda?

Each day I would hear helicopters overhead. I asked one of my friends about them, and learned that it was the president and his ministers being transported to an airfield in the good part of Kampala. Helicopters aren’t cheap. And somewhere in that observation no doubt lives the source of a sad narrative of institutional failure and of patients suffering from terrible diseases, who don’t have food to eat or a blanket to lie beneath.

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19:09, 5 October 2012 | Author : Doc_B

@therealmccoy There already have been Westerner deaths from filovirus - some deaths from Marburg in Europe, Ebola infections in USA associated quarantine facilities (no deaths, I believe), and two deaths from Ebola in South Africa. But granted, no spread outside of Africa resulting in the type of infection levels we see in say Congo or Uganda.

14:30, 3 October 2012 | Author : TheRealMcCoy

@Doc_B maybe once it kills some westerners, until then, no one will care

21:58, 2 October 2012 | Author : Doc_B

@JanetSP there are some interesting developments in filovirus prophylaxis that have been demonstrated in animal models. I should think that we would be trialling somehthing in the next decade, especially if outbreaks continue to increase in pace like they have been over the last decade.

10:41, 2 October 2012 | Author : David

Stuff of nightmares.

07:01, 2 October 2012 | Author : Savvy-bee

Interesting article. Sad the effect bad governments can have on ordinary people.


14:14, 30 September 2012 | Author : JanetSP

The scary thing is how little we know about ebola. If it made it over to the US or Europe, it could be very nasty. I've heard that all we know how to do is keep the patient comfortable and fed...and from the article, it sounds like even that can be hard depending on where the outbreak happens.

12:51, 29 September 2012 | Author : PaperbackWriter

Glad you're ok! That is some scary shit right there.