Friday, October 17, 2014
When Peter Piot, the 'Virus Detective Who Discovered Ebola', went to one of the first identified outbreaks in 1976 in the Democratic Republic of Congo, he reported that "it was clear that the outbreak was closely related to areas served by the local hospital".
Piot says: "The team found that more women than men caught the disease and particularly women between 18 and 30 years old - it turned out that many of the women in this age group were pregnant and many had attended an antenatal clinic at the hospital."
He goes on: "The team then discovered that the women who attended the antenatal clinic all received a routine injection. Each morning, just five syringes would be distributed, the needles would be reused and so the virus was spread between the patients."
What he has to say about people getting ill after attending funerals is repeated in contemporary reports on ebola in West Africa, ad nauseam. But the comments about visits to the hospital, women attending antenatal care and reuse of syringes (and possibly other medical instruments) are no longer mentioned so much.
The CDC does write that ebola "has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment", but they are not as expansive as Piot about exactly what that means on the ground.
There was a whole rash of recent reports about women being more likely to be infected with ebola than men in the current outbreak and a rather narrow set of speculative explanations about why this might be so, one being that women are more likely to be involved in giving care than men.
While women may well more often be the 'caregivers', an article in the New England Journal of Medicine summarizes available data on every reported case. However, it finds that there is very little difference in the numbers of men and women infected, and even the number of men who die from ebola.
There are also far fewer children infected than adults, despite claims that 'women and children' are more likely to be infected than men.
As far as I can see, media speculation into why women may be more likely to be infected than men (because they may have been more likely in some instances) did not question the possibility that women are often more likely to access healthcare, especially when pregnant.
Piot makes this connection during the first investigated ebola epidemic and goes on to connect women's elevated risk with the use of unsterile syringes, not just casual contact in healthcare facilities.
It is to be hoped that clinics are no longer issued with five syringes a day, though clear data about supplies of syringes and needles is hard to come by. But what about other infection control equipment and supplies; especially equipment and supplies in facilities that are experiencing extreme shortages?
What about facilities that are understaffed, where an adequate number of workers may be able to take certain precautions to protect themselves and their patients, but an inadequate number may only be able to think about their own safety, or not even that?
In the case of HIV there are many reasons why a woman might be more likely to be infected through unsafe healthcare. They are expected to attend antenatal care during pregnancy, give birth in a health facility, attend post-natal care, and perhaps several other reasons.
But since western countries, especially the US, have started taking an interest in ebola, they have reinforced efforts to round up people who look in the least bit like they have a fever and sticking them in an already overcrowded health facility, where conditions are appalling.
So if women were more likely to be infected with ebola earlier on in the current epidemic, and in some of the earlier outbreaks in other parts of Africa, perhaps the current approach is influencing the gender balance somewhat. One result possibly being that men are no longer less likely than women to go to a health facility (especially if they are given no option).
Piot says: "The closure of the hospital, the use of quarantine and making sure the community had all the necessary information eventually brought an end to the epidemic - but nearly 300 people died." Most people were quarantined in their own homes, not in an overcrowded and filthy ward.
How things have changed. Far from trying to persuade people to stay in their homes and supporting family members to look after them, US soldiers are helping to send people to what could be the very epicenter of the epidemic.
There are now far more confirmed and suspected ebola cases than there is hospital capacity to care for them. So a strategy that aims to strengthen and make hospitals safer, in combination with strengthening communities to care for people at home might now be the only option left.