A Perspective on Ebola and Public Health Issues in Africa

Contagion, the 1996 best seller by Robin Cook later transformed to a movie, and Outbreak, an earlier feature film, chronicle the public health implications of a deadly virus. Since January of this year, the world has been confronted with a devastating outbreak that is far from fictional: At least 2,000 people have been infected, and more than half of them have died, due to the Ebola virus disease (EVD) in several African countries. Ultimately, the disease’s impact on human life will be of far greater magnitude, the World Health Organization projects (Chan, 2014).

EVD was originally identified nearly 40 years ago in Zaire, now Democratic Republic of Congo, as a cocktail of five RNA viruses. Direct contact with bodily fluids from infected people or corpses is considered essential for transmission. The myriad non-specific flu-like symptoms make early diagnosis a significant medical challenge. Added to this challenge is the fact that the progression and virulence of the disease is variable (Feldman, 2014).

Following direct exposure, there is a 10-day typical incubation period. There ensues a rapid decay of the immune system, increased inflammation, and onset of impaired coagulation. Examination of infected populations indicates many are poorly nourished and present an impaired or ineffective immune system (Feldman et al., 2011). Thus, a compromised immune system and nutritional status exacerbate the potential risk of succumbing to an Ebola infection, and decrease the effectiveness of critical interventions, such as prophylactic vaccines. Several years ago, an initial vaccine based on vesicular stomatitis virus that is genetically similar to the rabies virus provided a foundation for the development of an Ebola vaccine effective in a macaque monkey (Geisbert et al., 2005; Reardon, 2014). At least three Ebola vaccines and four drugs have been developed, but have not been approved by the U.S. Food and Drug Administration due to insufficient testing (Enserink, 2014). However, this month, the FDA agreed that its Ebola lipid-encapsulated drug could be tested in those infected with the virus. A similar drug, ZMapp, appears to have been effective in treating physician Kent Brantly and aid worker Nancy Writebol, who contracted Ebola while doing missionary work in Liberia.

In the western region of Africa, the public health burden and healthcare resource disparities extend beyond Ebola hemorrhagic fever (Tambo et al., 2014; Fauci, 2014). Sub-Saharan Africa, which represents about 11% of the world’s population, contains nearly a quarter of the world’s global disease burden (Anyange and Mtonga, 2007). This disease burden, coupled with an insufficient healthcare workforce and inadequate financial support, elevate the serious nature of the current outbreak and challenges in developing solutions. Recent assessments indicate that perhaps a more effective approach would involve community-based interventions to improve nutritional status (Holdsworth et al., 2014). These investigators emphasized the critical nature of multidisciplinary collaboration, including nutritionists and those with specialties in food, agriculture, and behavior.  

Increased public health precautions are warranted. It seems only yesterday that virologists claimed the polio virus could not be transmitted as a respiratory particle. This is the current mantra promoted relative to Ebola. Perhaps virologists and public health officials should consider the purported oral polio vaccine-HIV vaccine theory, which contended the virus could be spread via compromised vaccines. This theory was refuted yet presented significant public health consequences, particularly in Africa (Hooper, 1999; Cohen, 2000; Worobey et al., 2004). While the scientific community dismissed the “contamination” issue, the scenario does prompt scientists to think about unanticipated changes in the viral genome and their potential associations with phenotypic manifestations.

While many in public health acknowledge the low numbers of Ebola, its virulence and clinical rate of progression must be taken seriously. A recent op-ed notes that perhaps the Ebola virus genetics have not changed, but suggests urbanization of underdeveloped countries may contribute to increased access to transportation resources and transmission vectors (Osterholm, 2014). One could argue that it is not simply the ethics of distribution of scarce treatment resources that is a major issue here; it is the bioethics of research and public awareness of the way we conduct research and response to public health disasters. 

Critical infrastructure assets, such as healthcare and adequate clean water supplies, are fundamental in curbing viral diseases. According to the most recent United Nations forecast, the total African population will nearly quadruple to about 4.2 billion by the end of the century (UNICEF, 2014). Is the local and global healthcare community ready to assume the public health burden that will ensue? Could the food industry participate in more rigorous and imaginative investigations and responses in this realm of public health? 

Roger Clemens, Dr.P.H., CFS,
Contributing Editor
Chief Scientific Officer,
Horn Company, La Mirada, Calif.
[email protected]