It has been heartbreaking to hear about the deaths of Dr. Khan and now Dr. Buck, both of whom were Sierra Leone's leaders in the fight against Ebola. This, of course, is not an unusual indicator in an Ebola disaster: the tragic death of an indigenous leader. It is reminiscent of the death of Dr. Kukwiya during Uganda's first recognized contact with Ebola in 2000.
Questions. Uncomfortable questions remain regarding the circumstances of MSF's decision making to utilize ZMapp for Dr. Kahn or not. Some question whether MSF actually allowed Dr. Kahn to make the informed choice himself. This, of course, ignores the possibility of whether Dr. Kahn was coherent enough to express a valid informed decision. And, there was the very real issue of killing the patient with an experimental drug, which would play directly into a widely held African belief of whites seeking to kill Africans using biological materials. It should be pointed out that two patients, a Liberian physician and Spanish priest, have died despite receiving Zmapp.
So, answers are not completely clear regarding the efficacy of ZMapp or convalescent serum as a valid life-saving treatment for Ebola... and most importantly, the relative efficacy versus aggressive IV fluid and electrolyte therapy provided at the earliest stages of the illness.
But then we have the prospect of a vaccine as well. And thus, questions cued (ahead of proof of human efficacy and safety) of who should receive the vaccine first?
At this point in the discussion we would point out there are significant drivers for mass migration that have been developing in Guinea, Sierra Leone, and Liberia. And we are seeing reports every week of people who have managed to leave the afflicted core countries, only to arrive at sites distant to the disaster zone in Africa, raising the prospect of having yet another country involved in the Ebola disaster. These drivers relate to:
- a grossly uncontained infectious threat;
- in the context of military / police-enforced restrictions to inter- and intra-country movement;
- food shortages;
- economic recession; and
- indigenous questions about actual presence of international responders versus pledges made.
Question #5 is uncomfortably similar to what many of us observed in post-quake Haiti's cholera disaster response effort, where promises of effort and donations were unable to be verified on the ground.
But let us focus on the concept of inhibitors to mass migration:
First, there is the sense of community cohesion, within which are the ties of family, friends, and profession that bind a people to their land. This is still powerful force in the region, as you still have stories of people trying to help each other (e.g. nurses still showing up for work, unpaid and risking their lives every day to save Ebola patients). Then, there is the presence of still-functional clinics (albeit grossly compromised), now augmented with the arrival of several new clinics, courtesy of the international response effort. This provides hope of care, and this is evidenced in stories of people bringing patients to these facilities as opposed to hiding patients. Unfortunately, these new clinics cap out quickly, where the supply has not caught up with demand...
What further augments this anchor of hope is, for example, Liberians to see a Liberian physician leading the response effort. This implies his or her safety and medical care is prioritized by the international community. The other side of this coin, of course, is the calculus of replacement. A very low percentage of well trained physicians who are native to impoverished countries remain in those countries. They often try to emigrate to a country with a far better economy. So, round after round of physician fatalities during Ebola disasters takes a deep, significant toll on that country's medical infrastructure. One that is not often rectified for years after the fact. The loss of Dr. Khan for Sierra Leone is going to be felt in that country for years.
There are many anchors of hope, such as food relief, that may also help balance the drive for a population to flee to other countries, where Ebola may be spread further afield. We often consider how to put the "fire" out, with contact tracing and medical care. But the other side of that coin is to counteract the drive for flight with anchors of hope.