Marburg outbreak, Angola: When saving lives seems cruel

One of the first questions people would ask us was: 'You're MSF, you're doctors, why don't you treat us? Why don't you have a cure?'" said Maes. “We had to deliver the message that, not only is the disease deadly, but on top of that, infected persons have to be isolated. That's a very bitter pill to swallow, and there's no sugar coating for it."

It is a human reaction: every one of us would be overcome with fear and anger if members of our family were suddenly taken away from their homes by strangers dressed like astronauts; if they were brought to a hospital; and if they came out a few days later in body bags, only to be swiftly deposited two meters under the ground without so much as a burial ceremony.

But aid workers fighting against Marburg - a highly infectious, rare, untreatable and deadly hemorrhagic fever resembling Ebola - had one, clear priority in mind: to contain the epidemic and save lives by isolating contagious persons and bodies as fast as possible.

The toughest challenge faced by MSF teams in Angola was how to adopt a sensitive, humane approach to one of the most cruel viruses on earth. Now that the number of new cases has dwindled to a near halt, MSF is taking the time to reflect on the lessons it has learned - sometimes the hard way - over the past four months.

“At first we were overwhelmed. The situation we encountered when we arrived was horrible," said Peter Maes, an MSF water and sanitation expert who works for MSF's infection control unit. “We had to chase after corpses decomposing in houses and morgues. There was no time to talk to the families. No time for mourning. The risk of contagion from dead bodies is very high, so it was urgent to bury them."

Backlash from fear

The backlash was that fear-inspired rumors quickly spread among the inhabitants of Uige - the town in northern Angola that was the focal point of the epidemic. Some of the inhabitants said the new foreigners were “stealing the dead" - a serious charge given the local belief that people who are not properly buried will turn into bad spirits and take revenge on the living.

Others claimed the “astronauts" (aid workers in full-body safety suits) were “demons" who were “confiscating the sick" or even worse, “killers" who had “come to exterminate us" by spreading the Marburg virus.

“It was obvious that we had to change our approach," said Maes. “And we did this as soon as we could."

He explained how, in early April, a couple of weeks after the epidemic was officially confirmed, MSF began “humanizing" the burials, notably by allowing family members to attend and participate: “Family members standing at a safe distance could see the face of the deceased when the body bag was briefly unzipped open, and those given protective gear could help carry and lower the coffin,"he said.

"... I think that one of the most crucial, yet most neglected, elements is communication and sensitization. If you don't do that right, everything else falls apart, because Marburg is transmitted and amplified by certain human behaviours."

 

To support MSF's medical teams, new reinforcements arrived, including staff members like Patrick Depienne, a sociologist who was given the task of informing and sensitizing the local population, explaining; how the virus is transmitted; what MSF is doing; why certain traditions such as washing the bodies of the deceased are extremely risky; and why isolating cases is crucial.

“Sensitizing the population is a priority," said Depienne, who worked six weeks in the province of Uige. “But of course it takes time and resources, and usually the first people to get to the scene of a disaster focus on the medical action."

Patrick's number one wish? “To arrive earlier. I wish I had gotten a seat in that first plane of aid workers that flew to Angola."

“Many aspects need to come together to control an epidemic like Marburg," said Dr. Armand Sprecher, a public health specialist who worked as a medical coordinator for MSF at the beginning of the Marburg epidemic. “If you want to have an impact, you need good epidemiological surveillance, good contact tracing, good case management, good logistics, good communication, etc., and the failure of one thing brings the whole house of cards down.

When communication is neglected

"But I think that one of the most crucial, yet most neglected, elements is communication and sensitization. If you don't do that right, everything else falls apart, because Marburg is transmitted and amplified by certain human behaviours."

The problem is that the list of risky behaviours is long, as the virus is transmitted by contact with infected and symptomatic humans - specifically, by contact with their body fluids, ranging from blood and breast milk to spit and sweat. Another problem is that, no matter how much effort is put into communicating about Marburg, for many reasons it is difficult to get persons suspected of having the virus to come to health structures where they can be diagnosed and, if needed, isolated.

The primary reason is that there is no cure for Marburg. MSF doctors and nurses can only treat the symptoms of the disease - such as high fever and dehydration - and reduce the suffering of dying patients.

One of the first questions people would ask us was: 'You're MSF, you're doctors, why don't you treat us? Why don't you have a cure?'" said Maes. “We had to deliver the message that, not only is the disease deadly, but on top of that, infected persons have to be isolated. That's a very bitter pill to swallow, and there's no sugar coating for it."

Some Angolan authorities opted for a hard approach.

"The government issued a decree saying that persons who refused to go to the hospital would be taken there by force," said Dr. Martin De Smet, MSF Emergency Pool Coordinator. “The problem with this strategy is that you'll get one person in the hospital, but all the others will run away. It might work in a small region, where there may be no way to escape, but Uige is a very vast province."

Another reason the beds in isolation wards can stay empty is that Marburg is hard to detect. Its symptoms, which include high fever, diarrhea and vomiting, are non-specific and similar to those of common, tropical diseases such as malaria. Marburg is not as dramatic and “gory" as media reports portray it to be.

“Patients don't bleed profusely from every orifice," said Dr. Sprecher who worked in Gulu, Uganda in 2000 and can compare Marburg to Ebola. But still Dr. Sprecher admits: “I think Marburg is even scarier. Because a person can feel a bit weak and look slightly ill but drop dead the next day. It makes you think the man sitting next to you in the bus might be infected."

While most infected persons unknowingly pass on the virus, some of them - for example one of the nurses who was working in the paediatric ward of a provincial hospital an hour's drive from Uige town - endanger the lives of others because denial and the fear of death prevent them from telling what they know or suspect.

As Marburg takes a heavy toll on health care personnel (16 died in Uige hospital, due to the absence or inefficiency of infection control measures), the disease can potentially lead to the collapse of a country's health care system. In addition, the stigma attached to medical personnel and structures, and the confusion surrounding symptoms means that many people with treatable diseases will avoid getting proper care and may end up dying at home.

Allowing visitors to come inside the isolation ward is one way to help de-stigmatize it. In Uige hospital, MSF was able to enforce the use of safety suits by the family members of isolated patients and, according to Dr. De Smet, “we realized that we could have higher transparency without compromising bio-security and infection control."

The role of survivors

The most effective “Marburg messengers" are patients who have been inside the isolation ward and come out alive. A 27-year old taxi driver named Horacio was the first survivor known to MSF and in early May, a few weeks after he was discharged and had regained his strength, Horacio was hired by MSF to raise awareness about Marburg and encourage other Angolans to come to the hospital.

A last resort when Marburg-infected persons refuse to come is “home-based risk reduction". “

It's a last resort option we can't afford to exclude and one that we began exploring in Angola," explained Dr. Martin Smet. “We make home visits, spend time with the family members, tell them not to touch the Marburg victim, and introduce hygienic measures. But of course we cannot observe if and how these measures are applied."

“There isn't much you can do against Marburg," said Dr. Sprecher, “so you have to keep an open mind and be creative with a limited arsenal of tools."

But what also matters is using these limited tools with sensitivity - as Maes' description of how MSF disinfected houses illustrates:

“We gave the head of the household a safety suit," he said, “and the neighbours, especially all the children, watched with curiosity as he dressed up outside and turned into an 'astronaut'.

"Then the head of the household went into the house with the MSF disinfection team, and together we made all the small judgement calls: we looked at all the objects - the TV, the embroidered tablecloth, etc. - and decided what to keep and disinfect by spraying chlorine and what to burn or throw away in a special waste pit."

Maes added with a smile: “Sometimes people would get a bit over-enthusiastic about the disinfection process, so we would do extra spraying, to please them and to reassure them that their homes were safe again."

Ironically, a simple solution of chlorine and water is enough to destroy a virus that is such a potent killer once it finds an opportunity to spread. In Uige, this opportunity was fortunately contained and it seems that Marburg will soon return to its dormant state.

But MSF will continue to closely monitor outbreaks of hemorrhagic fevers. And if it needs to intervene again, the organisation knows it can count on volunteers like Peter Maes, Patrick Depienne, Dr. Armand Sprecher and many others who have gained rare, first-hand experience and are willing to go “back to the field" as soon as they are called.