More than six months after the World Health Organization (WHO) confirmed an Ebola outbreak had taken hold in Guinea, the first known case of the virus contracted outside of the Africa in the current outbreak has been confirmed.
Health officials confirmed a Spanish nurse tested positive for Ebola after treating two Spanish priests who had contracted the virus in Sierra Leone and Liberia and were evacuated to Spain for care. One of the priests died in August, while the other passed away on September 25.
Adding to concern about Ebola infections outside of the outbreak zone where nearly 3,500 people have died, the news came the same day that a report was released that warns based on transmission patterns and flight data, the virus could reach France and the UK by the end of October.
The infection in Spain follows the first case of Ebola diagnosed in the US, in which a Liberian man identified as Thomas Eric Duncan came down with symptoms and was admitted to a Dallas hospital just days after flying in from Monrovia. He contracted the disease while still in the Liberian capital. With the the hospital's handling of the case under fire, the US Centers for Disease Control and Prevention (CDC) has taken charge of the situation — tracing contacts, holding press conferences, and working to educate the public on the disease.
CDC head Dr. Thomas Frieden has continued to push back against calls for halting flights from the affected region into the US. He has also continued to stress that the key to keeping the disease from spreading in the US is to halt the outbreak in West Africa.
While this may be the first time the CDC is working to contain the Zaire strain of Ebola on American soil, the public health institution has been a key player in Ebola response efforts for decades. Then known simply as the Center for Disease Control, the institute had a team on the ground during the first known outbreak in 1976, when the hemorrhagic fever showed its face in the central African country then called Zaire.
Alongside a group of international scientists and medical experts, the CDC assisted in controlling and investigating the outbreak of what was at the time a mysterious and deadly new disease. The fever first showed up in rural forest villages, later devastating a mission hospital in the village of Yambuku by killing a majority of the staff. The virus spread to a total of 55 villages between August and November of 1976, infecting 318 people and leaving 280 dead. Stepping into a fearful atmosphere, the scientists worked alongside local leaders and villagers to contain the spread of the disease. With a host of unknowns, the medical experts worked to provide clinical care, maintain cultural sensitivity, and learn more about the Zaire strain of the Ebola virus.
Both Zaire and the CDC have since gone through name changes, now known as the Democratic Republic of Congo and the Centers for Disease Control and Prevention respectively, but many of the response mechanisms used to put a stop to the first outbreak have proven tried and true in the ones that followed.
In a recent paper, the retired National Institutes of Health scientist Dr. Joel Breman, who worked for the CDC during the 1976 outbreak as part of the International Commission for the Investigation and Control of Ebola Hemorrhagic Fever in Zaire, describes actions his team took at the time and explains that "steps from the first Ebola outbreak may help bring the current epidemic under control." VICE News spoke with Breman about his experience and how it relates to the 2014 outbreak in the West Africa.
VICE News: Can you talk about the period surrounding the 1976 outbreak, your arrival in the outbreak zone and the mood on the ground
Dr. Joel Breman: The tone on the ground was sheer terror and panic because [by then] they had now heard of a mysterious disease, something that they hadn't seen or dealt with before — particularly the people in the epidemic area, but the word spread fast in the urban zone in Kinshasha, the capital of now DR Congo. And then bleeding began. That is not so common with the things that they were talking about that they thought might have occurred, and had occurred in epidemic proportions in decades past, such as yellow fever and typhus and cholera and smallpox. The signs and symptoms were new, but in particular, there were so many deaths.
Then when they found out the health staff and Belgian nuns were getting this disease and dying, the terror, the panic, and confusion about this disease accelerated. So that was the population, and when I say population a lot of people in the government and in some, quite frankly, international organizations that were confused as well about what was going on and should be done. I mention health staff, because we were also, to be frank, fearful of the unknown, but we have our job to do and I think once we banded together to find out what had to be done, then things calmed down — at least for us.
At the time, it was a new disease. How did you work with the local communities? Were there any culturally specific approaches you adopted?
Using the local people was crucial in terms of leadership and decision makers at every level to interpret what was going on. Secondly, trying to use western medicine as best we could, and public health under those conditions. So there was never any question that the Zairians were the leaders. The minister of health was in charge, and he was in part US-trained, but also a very thoughtful guy who had a lot of support from other people in the country — both psychologically, as well as materially.
Then when we were out in the field we would deal with the local governor, the village chiefs, always explained what we were doing, and the families. I must say because we were in the field, working with a religious community where the nuns had been there for, let's say, 40 years or so doing all these marvelous social action projects — from agriculture to education to health, home economics, and religion — that there was a certain trust even though the mission hospital had been the site of epidemic and center of spread.
So I think [to answer] the question about understanding the local practices: by asking questions, observing and taking advantage of them, and also explaining the science. Yes, there was terror and fear that this could have been a spirit for bad behavior or something that the community had done wrong or that they were being punished or that it came from outside the realm of what was known. But, this is my belief, that by bringing some electron micrographs of this very strange looking virus and showing them that we knew, as doctors in public health, that we knew what was the cause — it wasn't something that we couldn't pinpoint. While we didn't know a lot of things, we always knew what caused it. I think that, in part, made it easier for cooperation. Plus people in the villages were doing some of the right things. That's how we dealt with it, by using local leadership, local people of influence, explaining science and then marshaling what we knew in terms of Western medicine for treatment.
The World Health Organization has talked about the importance of having doctors and nurses in developing countries stay in rural areas, instead of moving to urban areas or abroad. How do we build more robust public health systems in rural areas, specifically in developing nations?
That points far wider than Ebola and it's important because most of the health problems faced by these people, even today in the countries affected by Ebola, go far beyond the catastrophe that's going on now. We're talking about malaria, diarrhea, pneumonia, obstetrical problems, and on and on that the population and health care providers face all the time. So you have to have doctors and managers out in rural areas where a large percent of the population live. So my view is that training is key... With the Ebola situation today, where the health systems are now fractured and they were very weak and inadequate to begin with — now they're nonfunctional in certain areas. We're talking about transport, ambulances as needed, we're talking about communications most importantly. Training to do the right thing, and supply of equipment and the right personnel, both surgical, medical, pediatric, psychologic. Someone has to see the big picture there and Ebola is just one part of it, one menace that they face today.
A lot of the approaches you took in 1976, proved to be effective in all of the following outbreaks. In this 2014 outbreak, how do you explain the effectiveness gap in those outbreaks and the current one? What do we need to change?
There have been 24 other outbreaks of Ebola since then, and you're absolutely right, the tried and true measures have ultimately worked once the disease was reported and resources were marshaled in. [The 1976 outbreak] started with a hospital-based, health system outbreak and unsuspecting health workers — misdiagnosed rectal bleeding, or an acute abdomen, or an aborted baby — then the blood got transmitted from the patient to the health staff. And that's what's going on now. [In Zaire it] didn't get into large urban areas and wasn't maintained through these travel routes like today. That is the main problem.
What's interesting [in this outbreak], early on the patients were running away from the health system. Now they're clamoring to get care, but they can't find it and that's a tragedy. On the public health side, the thing that we did early [in 1976], and I must say the communities were doing it, was isolating themselves. What they knew from small pox and maybe leprosy and other epidemic disease they had [experienced], was that just staying put was the thing to do and not to start running far and wide.
There's so many deaths [in the 2014 outbreak] and once someone dies, the body is teeming with virus, they're very infectious, it's exceedingly important to bury the patient immediately. And that's a big challenge because of the traditional burial practices. So these are the challenges and these are different, and I do think that there are local solutions. Sitting here far away we can speculate and say what we did, but the answers are local.
We're going to see Ebola again. What information are you looking at now from the current outbreak? And when this burns itself out and you're looking back, what kind of information are you hoping to learn to help in the future?
On the virologic side some information is even coming out, since I wrote the paper, saying that the virus has not changed greatly from early on. So this is more reassuring, there's been this rather alarmist speculation that the virus is mutating and that other modes of spreading might occur. This has not occurred, the virus has not mutated. So we're dealing with the same virus, that has occurred in all the other outbreaks caused by Ebola Zaire. What we would love to learn is more how transmission is occurring in this urban setting. We're speculating that the same person-to-person contact is occurring, but the people are now getting in taxis and driving for hours and hours not being able to find a treatment center. So their family members are smeared with the body fluids of the contaminated patient. There's already information coming out in regard to length of incubation period and time interval between [when] a patient gets sick and the next patient gets sick as well.
But for me what I'd like to learn more about is the ecology. We still don't have it totally nailed down how bats or the non-human primates, be it monkeys, apes, or chimps, are in contact with patients. We know that they can harbor the virus, and bats can have an asymptomatic infection, but there's not a lot out there about bushmeat in regard to eating these species that can harbor the virus. And whether these are popping out frequently or they just start these epidemics and then they carry on.
On the anthropology side, the behavior of people when they're fearful of a disease. What motivates them to go to a treatment center or not to go? Or to go to the traditional healer or not go? Or to educate themselves and their community about this? What are the messages that can be given?
With boosted response, what's your outlook on the epidemic going forward?
I wouldn't be in this business still today unless I was an optimist. I would say that I am hopeful with a modest degree of confidence that this is going to be conquered, this epidemic. If they break it down into doable pieces, in regard to patient management of both Ebola and non-Ebola diseases, searching and isolating patients and contacts and tracking them, and quick burials even in urban areas.
This is not a highly transmissible disease. It's a blood borne disease like HIV, like Hepatitis. And with personal protection and proper protection, the management of patients and cadavers can be safely handled. Once you get the disease it's not good, so from that point of view, I'd like to share a glimmer of optimism, because I've seen it. I've observed it occur in multiple other outbreaks.
Follow Kayla Ruble on Twitter: @RubleKB