Al-Ahram Weekly On-line 16 - 22 November 2000 Issue No.508
Published in Cairo by AL-AHRAM established in 1875

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Fear of the unknown

By Nyier Abdou

It can begin with symptoms as innocuous as stomach cramps and tired muscles, but it can end in the unthinkably grotesque -- bodily shock, uncontrollable bleeding from orifices and, often, death. It is patient, waiting up to 10 years before levying its next strike, and then swift, killing up to 300 in one spell. It is incurable, unforeseeable and improbably contagious. For the people of Uganda, it is yet another cross to bear.

Since its discovery in Zaire (now the Democratic Republic of Congo) in 1976, the hemorrhagic fever known as Ebola -- named for the Ebola River in northwestern Congo -- has killed over 1,200 people, needing only a handful of isolated outbreaks to do so. More than two decades of research has yielded little in the way of understanding the Ebola virus, or even suitable precautions against outbreaks. Because the initial symptoms of Ebola are almost indistinguishable from those of a cold or flu -- or less virulent and more common diseases like malaria -- it is difficult to nip an outbreak in the bud. By the time enough people have died to raise the cold sceptre of suspicion, the virus is already being carried and passed on. From there things move very quickly.

So it was when a woman in the northern Ugandan district of Gulu, about 225 miles north of the capital Kampala, died suddenly in early September, followed quickly by several of her relatives. In an area as remote, underdeveloped and besieged by rebel activity as this one, one death is not cause for concern. The run-down hospital facilities were better known as sanctuary against attacks by forces of the opposition Lord's Resistance Army than for their embarrassingly inadequate medical facilities. Poor sanitation and close living quarters were an ineluctable breeding ground once the virus infiltrated the community. Health officials swooped in when three nurses at the hospital died, but by the time the cause of the deaths was positively identified as Uganda's first instance of the Ebola virus, it was mid-October and the outbreak was well under way.

Teams of international experts, coordinated by the World Health Organisation (WHO) and Uganda's Ministry of Health flew to the scene with equipment, medicine and protective gear no less unwieldy and airtight than what one would expect to wear for a walk on the moon. The Geneva-based Médecins sans Frontières (MSF) -- Doctors without Borders -- is working with doctors from the Atlanta-based Centers for Disease Control and Prevention (CDC), a research arm of the US Department of Health and Human Services, to isolate and contain the outbreak. Although outbreaks have been seen in Congo, Sudan, Gabon and Ivory Coast, health services can only act after the fact. One cannot guard against the unknown, especially when so many other threats are already praying on the population.

Asked if the Ugandan Ministry of Health was prepared for this level of crisis, WHO spokesman Gregory Hartl told Al-Ahram Weekly that health officials and doctors can only move swiftly, isolate cases and, most importantly, trace back all contacts. "At the end of the day," Hartl said, "in public health terms, it happens so rarely -- it doesn't kill too many people, when you think about it [in relation to] AIDS."

Specialists combed the area for anyone who may have come in contact with the virus and were growing confident that they had managed to contain the outbreak. But cases outside of Gulu are slowly trickling in. Four people have died in the southern district of Mbarara, 175 miles southwest of Kampala, and earlier this week another case was identified in the district of Masindi, 112 miles northwest of the capital. But Hartl dismissed these as isolated incidents. A total of 323 people have been infected with the Ebola virus, more than 110 of whom have died, making this outbreak one of the worst since the 1995 outbreak in Kikwit, Zaire, which killed 315 people.

The Ebola virus is classified into four strains, three of which affect humans and one that has only been known to affect non-human primates, namely monkeys and chimpanzees. In most cases, the virus is extremely lethal -- up to 90 per cent fatality rates have been recorded -- but depending on circumstances, particularly the medical facilities in the area, as many as 50 per cent of those infected can survive. So far, the fatality rate in Gulu has remained impressively below 50 per cent and international teams have praised the Ugandan response. "Basically, Ugandans have been excellent throughout," Hartl said. "This is the best response we've had to Ebola yet."

Though there is no known cure for Ebola, people can survive when the virus is detected early, but survivors can remain weak. Even worse, MSF spokesman Wyger Wentholt told the Weekly that patients who have recovered can be shunned. "Not everybody understands that [the recovered victims] are no longer a source of infection, and there have been some isolated cases where recovered patients were rejected from their village."

The virus literally dissolves its victims from the inside, causing massive bleeding and bodily secretions -- all of which carry the virus and are possible contaminants. Because of its grisly symptoms, one would have thought it was difficult for health officials to keep residents in the area. But Wentholt told the Weekly that residents and workers have been remarkably straight-backed under weeks of pressure and fear. "It is significant overall that people have remained composed. As a matter of fact, the dedication of the hospital staff is absolutely admirable," Wentholt said.

The virus can only be transferred by bodily fluids, but it can be something as simple as drinking from the same glass of water or even sharing a cigarette. In rural Uganda, where funereal rituals traditionally include a communal washing of the body and a shared meal, it is easy to see how quickly the virus spreads. But the aching question still remains: how did it get there in the first place?

What makes Ebola so deadly is how little is known about it. Scientists have been unable to determine its "natural reservoir" -- the natural environment where the virus resides -- but the suspicion is that it lives in an animal host that is native to the African continent. Still, no one knows how or why the virus makes the jump to its first human case. Ebola is so virulent, however, that it usually kills itself by taking victims faster than it can spread.

The Ugandan outbreak has been identified as the Ebola-Sudan strain, last seen in Sudan in a 1979 recurrence of the 1976 outbreak that took 284 lives. The Sudanese link has fuelled speculation that the virus was brought by Sudanese-based guerrilla fighters of the Lord's Resistance Army, who have plagued northern Uganda for over a decade. But this only further begs the question of why now, more than 20 years later?

Now well into its second month, the crisis seems to have levelled off. WHO's Hartl seems confident that the worst is over. "It's not spreading," Hartl told the Weekly. "I don't foresee a huge new flare-up." MSF's Wentholt agrees, saying that among MSF doctors, "there's a feeling of optimism now that there seems to be light at the end of the tunnel." Wentholt noted that people in Gulu are "keeping their spirits high... this new disaster is taken in the same spirit of tough resilience that they have been showing for a long time."

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Related links:
Medecins sans Frontiers
International Committee for the Red Cross
Centers for Disease Control and Prevention

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