The ebola-virus: ... and the Challenges to Health Research in Africa.

Sometimes, it seems that much of Africa almost courts misery, reading like the script of a bad action movie, everything happening at once -- disease, natural disasters; war, epidemics -- a Hollywood producer would likely throw it out as too unbelievable. As the Ebola epidemic started to wane, I finally had a few minutes to get to know some of my co-workers -- the human beings behind the surgical masks. One day, in between screening patients, a young nurse named Christine told me her story -- the story of Africa's other epidemic. Her father, mother and brothers, all dead from AIDS; she and her sisters are left behind, trying to make the best of things. She recounted the tale almost casually, not because it wasn't tragic but because, tragically, it wasn't unusual. What's more, suffering caused by malaria and tuberculosis is so common that people generally fail to recount stories about it at all.

To survive to old age in muck of sub-Saharan Africa, it seems you have to run the gauntlet. Only a strong disposition, and perhaps a good dose of luck, buys you longevity. Children survive the respiratory and diarrhoeal illnesses of childhood, only to face new threats of AIDS and Ebola, wars and automobile accidents. Too often if one thing doesn't get you, another will.

Lest we become overly pessimistic, it should be noted that there is cause for hope. Africa has many resources upon which to draw--incredible cultural diversity, a tradition of creativity and perseverance, wealth in the form of minerals and natural resources. Most notably, I have always been impressed with the civility, liveliness and depth of the social structure in many African countries, the respect for elders, the strength of the family unit, the sense of duty. Answers may take time, perhaps generations, but we have to start looking now. Even the continents that we presently consider more "developed" emerged out of complex periods with similarities to present-day Africa.

African success stories exist. Public health initiatives have recently scaled back the AIDS epidemic in Uganda. Even Ebola can have its happy ending Like Onenchan Jones. The day before I left Gulu, he came back to the hospital to visit me, along with his eleven children. Feeling good, with a huge smile on his face, he offered to give me a chicken. Say what you want about tragedies in Africa, but you've never seen someone so happy to be alive.

This is the main road in Gulu, Uganda.

Onenchan Jones looked at me through sunken fearful eyes, Doctor. I'm dying," he said simply. It wasn't a declaration but a plea. Weak, whispered, far away a voice already half dead. Given his condition and that he had seen friends and family die of Ebola. I silently supposed he was right. It was just a matter of time until his motionless body would have to be counted as another corpse. Thus started my first day of work on the Ebola ward at Gulu Regional Hospital in northern Uganda.

As it always seems to go. I had returned from a long trip to West Africa just a week before, working on an outbreak of a related viral disease. I was planning on settling back into Atlanta, catching up on e-mail, plugging away on some manuscripts, and getting some rest and execise. But late on a Friday afternoon last October in came my boss. Pieire Rollin, pulling up a chair and sitting down on it backwards, his arms folded across the backrest, the way he does when he has something definitive to say. "This thing in Uganda is Ebola. We got the results from South Africa today." After a frenzied few days of packing equipment and arranging travel details, we were off to Gulu, a team of six from the Centers for Disease Control and Prevention (CDC), United States.

I must confess, despite having spent a lot of time in developing countries over the past decade, I wasn't quite prepared for what was about to come. I had seen more cases of viral haemorrhagic fevers than your average doctor. I had not yet seen Ebola, but how different could it be? I had scoffed at a lot of the exaggerated popular literature about it, describing melting eyeballs and all.

So, as much as anybody can be I figured I was prepared for these things. I think most of us going in fel that way. But that was before Onenchan. Before so much upheaval. And before Dr. Lukwiya's death.

Dr. Matthew Lukwiya known to his colleagues simply as "Dr. Matthew", "upped the ante" on the scale of tragedy of the Culu Ebola outbreak. His death was the sort of thing you thought could never happen, misfortune that existed only in books or films. As the Medical Director of one of the primary hospitals affected by the outbreak, he was an the heart of the matter in vitually every way possible. But his involvement wasn't just circumstantial. He was a talented, dedicated man, the first to put together the pieces of the puzzle and suspect that Ebola was the culprit killing his patients. Those who knew him are not stingy with words of praise--healer, scientist, gentleman, leader, friend.

Two thirds of the way through the epidemic. Dr. Matthew suddenly developed a fever. A week later, his name was added to the registry of Ebola deaths at the very hospital where he worked. Those of us "experts" visiting Uganda knew the havoc that Ebola could cause having seen so many deaths and the total upheaval the epidemic caused in the Guhu community. But until Dr. Matthew's death, we managed to somehow look on as outsiders observing the chaos, peering in through wat we took to be the protective cloak of our scientific training. We were watching a battle from a faraway hilltop, recognizing the horror but not feeling personally threatened. Dr. Matthew wasn't the only hero nor the only health care worker to die, but when he went down, everything changed.

We then realized the chaos could come even to our door. This is not to say that we had no concern, no fear, prior to Dr. Matthew's death. Every day the slightest hint of a headache or fever would cause health care workers and citizens alike to seek us out. "Doctor, I think you better test me", they would request, sticking out an arm as if I had a needle and syringe ready. Nor were we immune to these fears. Most of us, expert or not would have to admit to days when sweating in a plastic wrap of protective gowns, gloves, aprons, masks and goggles, we wondered if it was just particularly hot that day or maybe we were especially tired, or was this the first day of a fever? One usually kept his mind from thinking too seriously, too far ahead. But that again, was before Dr. Matthew.

An Ebola outbreak in a community causes complete upheaval to virtually all facets of society. It is an event that divides time into a "before" and an "after". After, whether you personally were infected or not, nothing can ever again be the same-no person is left unaffected, no emotion unturned. The individual agony of those stricken with Ebola is readily apparent, but the losses run much deeper. Scared neighbours, sometimes even family members, refuse to let convalescent patients back into their homes, sometimes burning their belongings or their entire hut. Deep-rooted African customs regarding burial of the dead are disrupted. Traditional funerals, which often entail ritual washing and touching of the corpse, are suddenly forbidden. Reactions are mixed. Initially, family members may resist the change. Later, as the destruction wears on, fear takes over. Working on the ward, I would have letters handed to me, such as the one that stated: "Our brother reported sick this and but passed away before being broug ht to hospital from 'unknown, sickness which started only last 2 night. People have run away from home. Let the burial team come collect the body and bury." Burials, traditionally done around the home, now take place in graves designated for those with Ebola, a life turned into a white plastic body bag, in seven days time.

Back in Atlanta, the Ebola outbreak behind me. I readopt the plans I had when I left, catching up on work, sleep and exercise. But for me too, Gulu represents a before and an after. I slowly try to make some room in my brain amidst data to be analyzed and phone calls to return to understand what it all means to me. It's a slow process that can come to you only at an angle, like how you can see a faint star only by looking out of the corner of your eye. The image in my eye has not yet completely formed, but I think it's mostly a simple but graphic reminder of our mortality, a timeless message about the fleetingness of life, a nudge to call your family more often.

Paradoxically, more pragmatic questions are often more difficult to answer than the grandiose philosophical ones, perhaps because we expect a more concrete answer. I try to put Ebola in the context of the great burden of health problems of Africa. What does it mean? As a researcher and a health care worker, what can I do about it?

Although perhaps one of the most dramatic, Ebola is far from being the biggest threat to health in sub-Saharan Africa. Sometimes, it seems that Africa almost courts misery, reading like the script of a bad action movie, everything happening at once-disease, natural disasters, war, epidemics-a Hollywood producer would likely throw it out as too unbelievable. As the Ebola epidemic' started to wane, I finally had a few minutes to get to know some of my co-workers-the human beings behind the surgical masks. One day, in between screening patients, a young nurse named Christine told me her story-the story of Africa's other epidemic. Her father, mother and brothers, all dead front AIDS; she and her sisters are left behind, trying to make the best of things. She recounted the tale almost casually, not because it wasn't tragic but because, tragically, it wasn't unusual. What's more, suffering caused by malaria and tuberculosis is so common that people generally fail to recount stories about it at all.

To survive to old age in much of sub-Saharan Africa, it seems you have to run the gauntlet. Only a strong disposition, arid perhaps a good dose of luck, buys you longevity. Children survive the respiratory and diarrhoeal illnesses of childhood, only to face new threats of AIDS and Ebola, wars and automobile accidents. Too often, if one thing doesn't get you, another will. Dr. Matthew was once abducted by the Lord's Resistance Army-a rebel group active in northern Uganda-held for a few days and then released. He survived that round, but wasn't so fortunate in the Ebola category.

In some ways, the situation in Gulu seems to typify the biological, social and political upheaval seen across much of the African continent. In response to this apparent chaos, outsiders often tend to throw up their hands, say "what a mess", and turn their attention towards the fate of the Euro or whether new markets will be opening in China. And the frustration is understandable, for easy answers are not forthcoming.

When something as dramatic and deadly as Ebola breaks out, a host of resources are mobilized and a United Nations-worth of organizations converge on the epicentre to help put out the fire. They generally do an effective job, but return just a few months later and one usually finds that it's back to business as usual. Short-term financial commitments for a high-profile outbreak are relatively easily forthcoming, but long-term support for the public health infrastructure necessary to truly understand the epidemiology of these diseases, and thus possibly prevent them in the future, is scarce. This is unfortunate, as long-term investigations exploring their natural history--where they come from, how they are transmitted from one person to another--would ultimately have far more of an impact on health than the measure of our emergency response to any single given outbreak. The point is not that one is more important than the other, but rather that if there was more of the former, there would be a lot less need for the latter.

What are the impediments to long-term scientific research in developing countries and, through it, better health? An initial, fundamental but perhaps philosophical, question harkens back to a debate that has raged since the late eighteenth century when politicians argued over whether the new United States of America should be an "isolationist" or "interventionalist" nation. "Globalization" being the word of the day, it seems the latter sentiment has prevailed. But while we perhaps accepted this economically, we have stopped short of a true commitment to health on a global scale. Rather, we are witness to a call to return to a sort of bioscience "isolationism", with Governments of many industrialized countries reorienting their budgets toward those health problems deemed to be in the "national interest". But whereas nations have boundaries, pathogens have none. With regard to health and disease, what national interest can be separated from our collective international one? Examples of this connection are rife: the importation of West Nile encephalitis into the United States in 1999, a patient with Lassa fever transported from West Africa to Chicago, protection from the threat of biological warfare. Myriad arguments can be made to support how engagement overseas can lead to increased economic and political stability and improved health for all. But even if we discount them, does a rich nation really need a reason to engage with a poor one?

If researchers at many African institutions have little to do these days, it is not for lack of trying. At almost every institution I visit, someone pulls me aside to propose a collaboration, sometimes even handing me a written proposal for my feedback. A recurring theme and obstacle in these proposals is differing research agendas from those of investigators from industrialized countries. African investigators appropriately tend toward applied research addressing the needs of African communities, while outsiders may be more interested in relatively abstract molecular characterizations, the protection of travellers, or the danger posed by the occasional imported case of a communicable disease.

While both approaches are important, and as funding most often comes from the foreign donor, projects do not always translate into health research with direct benefits for African countries. This will likely come only when African nations have the institutional and financial autonomy to have a bigger role in setting agendas.

Many of the obstacles to establishing research programmes are not exactly scientific. Too often, even when there is technology to be transferred or a collaboration to be undertaken, there is an absence of competent and accountable partners with whom to engage. Politically incorrect as it might be to point out, corruption and political boondoggles have stifled many programmes. I remember seeing a luxurious three-storey house being built in a small town, an almost space-age structure intercalated among traditional mud huts. "That's the district officer's house", my companions explained. "He was appointed last month." A glaring example perhaps, but not uncommon.

Change will not be easy. As an African colleague of mine observed about corruption: "When everyone growls like a wolf, you must not cry like a sheep." Issues of accountability are, of course, by no means unique to developing countries. African Ministries of Health have often watched helplessly as studies executed in their countries conclude, the academic benefits going to institutions in industrialized nations, the profits to multinational drug companies. Improved leadership and accountability are needed on al sides. And then there is the civil unrest that too often stifles development, scientific solutions to health problems await political solutions to broader conflicts. The CDC research project for Lassa fever in Sierra Leone finally succumbed after 20 years, a different sort of casualty of the civil war.

In fact, it's hard to think of a project or outbreak response that I've been involved with in Africa that hasn't had to contend with some degree of civil insecurity. The viral haemorrhagic fevers and violence strangely go hand in hand: Lassa virus in Sierra Leone, Marburg virus in the Democratic Republic of the Congo, Ebola in northern Uganda. In Gulu, suspected cases of Ebola often could not be adequately traced in rural areas because of the need for military escorts for virtually any travel outside the town centre. Violence in Sierra Leone and Liberia has recently spilled over into Guinea, threatening the future of the IRBAG-GDC field station there.

Toward a solution

Where to begin, what steps to take toward amelioration of the health problems facing the African continent?

The problems and countries are diverse, and no single solution will do for all. It is unrealistic, of course, to talk of "Africa" a singular entity, boiling the most diverse continent in the world down to one homogeneous handle. Nevertheless, there are some themes that could broadly apply.

A first supposition must perhaps be this: solutions to the health problems facing Africa are as likely to be found in the domain of the political sciences as the biological ones. Biological, political, social--they are inextricably linked, perhaps "entangled". Approach an issue about health and you will soon get to economics, which will lead to politics, societal traditions and human rights.

Ebola is atypical in this regard, the rare apolitical pathogen, a truly indiscriminate killer. Details of the virus and its reservoir remain a mystery, making public health recommendations for its prevention difficult. But for most of the diseases that plague us, whether we like to admit it or not, we already possess the scientific knowledge necessary for their control, sometimes even their eradication. Putting the necessary political, economic and social drive behind this knowledge is another story. This does not mean that all people need to do all things. Rather, it implies a need for communication, an appreciation of the "interconnectedness" of problems and disciplines. Then, recognizing this, we generally tear off a piece according to our discipline, sculpt it as best we can, and try to fit it into the bigger picture. Think globally, act locally.

What is needed is a new paradigm of "engagement", or perhaps a partial return to an old one. In a previous era, field stations in developing countries were often maintained by colonial powers, albeit with a degree of paternalism and controversy. With the passing of age, many of these units closed, depriving researchers from developing and industrialized countries alike of training sites to study the tropical pathogens that collectively plague us. While no one would suggest that we return to the colonial days, we must recognize that the closing of these units also represents a missed opportunity, a loss of potential knowledge, and a vacuum of young researchers truly versed in the study of tropical pathogens.

In place of overseas field stations, shorter-term projects are often proposed, sometimes with technology transfer to the developing country and training grants for African personnel to study in industrialized countries. But the issue is more complex than simply sending microscopes and providing research fellowships. Educated people cannot work in intellectual isolation in their home countries. They need equipment, projects, collaborators, salaries, stable institutions--an "academic home". Without this, the seed of productivity is perhaps sowed but the harvest never reaped. Ironically, the benefits often go to industrialized countries, as these individuals often join the "brain drain"--the flow of the educated and trained to a more fertile academic environment outside their country of origin.

One thing appears certain: translating scientific research into better health will increasingly require partnerships that wed a broad range of organizations and disciplines. No single organization is capable of offering all the expertise and services required, conducting basic science and epidemiologic research, producing drugs and vaccines, providing health care and relief services. Furthermore, no mechanism is in place, in Africa or elsewhere, to consistently funnel basic science advances through to public health practice. A haphazard jumble of academic curiosity, free market capitalism and altruistic activism sometimes translate into advances in health. But all too commonly, the ball is dropped somewhere along the line.

The basic science knowledge may be there, but this information is not used to develop an appropriate drug or vaccine. Or perhaps a drug exists, but the African nation is too poor to supply it. Often a governmental or non-governmental organization (NGO) identifies a problem or need, but the basic research to confront it is lacking. One proposed solution might be to try to take the element of chance out of this chain of events, to make it more longitudinal and directed. What could be achieved if an African Government teamed up with, for example, a research institution, an NGO and a pharmaceutical or biotechnology company to tackle together an identified health problem? Training and technology transfer, research and product development, and distribution of services could be put in the context of a bigger picture, a goal in mind that all could identify. Each organization would make an upfront commitment to perform its task, then hand the ball over to the next partner. Basic science researchers and epidemiologists would have extra incentives knowing that the data they collect will not be "orphaned", as it frequently is today, but used by biotechnology companies to produce viable products. In turn, NGOs and Ministries of Health would form partnerships to ensure that these products are applied where they are needed most. The time-line might have to be a long one, and the way budgets proposed drastically changed, but is this perhaps any more problematic than the circuitous and haphazard route presently followed to translate biomedical research into better health?

Lest we become overly pessimistic, it should be noted that there is cause for hope. Africa has many resources upon which to draw-incredible cultural diversity, a tradition of creativity and perseverance, wealth in the form of minerals and natural resources. Most notably, I have always been impressed with the civility, liveliness and depth of the social structure in many African countries, the respect for elders, the strength of the family unit, the sense of duty. Answers may take time, perhaps generations, but we have to start looking now. Even the continents that we presently consider more "developed" emerged out of complex periods with similarities to present-day Africa. African success stories exist. Public health initiatives have recently scaled back the AIDS epidemic in Uganda. Even Ebola can have its happy ending. Like Onenchan Jones. The day before I left Gulu, he came back to the hospital to visit me, along with his 11 children. Feeling good, with a huge smile on his face, he offered to give me a chic ken. Say what you want about tragedies in Africa, but you've never seen someone so happy to be alive.

Daniel Bausch is a medical epidemiologist at the Special Pathogens Branch of the Centers for Disease Control and Prevention in Atlanta, Georgia. He is board-certified in internal medicine and infectious diseases, with a Masters degree in public health and tropical medicine. Dr. Bausch specializes in viral haemorrhagic fevers and has extensive experience in research and outbreak control in Africa and Latin America.

RELATED ARTICLE In the West African country of Guinea, researchers mill about the worn walls of the Guinean Institute for Research and Applied Biology, known by its French acronym of IRBAG. Most people still call it by its old colonial name, "Pastoria", belying its beginnings as one of the many Pasteur institutes the French peppered around the globe. Pastoria tells a familiar story of colonial powers that come and go, bringing with them, for a time, scientific technologies that would to benefit the populace. Under the French, Pastoria was a top-notch facility engaged in a wide array of research disciplines, studying malaria and sleeping sickness, producing snake anti-venoms and the Yellow Fever vaccine, even studying primate behaviour in semi-natural habitats. But with Guinean independence in 1958 came the equally independent spirit of President Sekou Toure, breaking definitively and acrimoniously with the French. Charles Gaulle returned in kind; suspending support and dismantling infrastructure virtually ove rnight. Pastoria, left to fend for itself in a poor nation, fell into disrepair and virtual disuse.

During the cold war, Guinea leaned toward the Soviets, who rejuvenated the Institute. At its height in the mid 1980s, Soviet researchers and their families at the Institute numbered over 70 people. Buildings were erected, equipment imported, studies put in place. Scores of Guineans were sent to train in the Soviet Union or Cuba. Even today, two former classmates will chance across each other in a small Guinean village, breaking into Russian, laugh the snow, about the challenges they faced as black Africans in the white world of Soviet Russia.

But what they rarely have occasion to do is discuss research collaborations. The fall of the Soviet Empire again brought a precipitous withdrawal of a superpower from Guinea, again leaving Pastoria on its own. Most days now, I you find researchers waiting to see what comes next, suspended in history, educated ghosts haunting the old offices and laboratories, one sign on a door in Pasteur-era French, another in dusty Cyrillic lettering; complete with hamer and sickle. They still recount the scientific details of their disciplines and research, but most often the story with the fall of the Berlin Wall. Nor is the story of Pastoria necessarily an unusual one. Across the continent, there are laboratories and programmes started in good faith, now the domain of historians.

But like the proverbial phoenix, IRBAG is again showing signs of life. In 1996, the Institute and COC started the Guinea Lassa Fever Research Project to study viral haemorrhagic fevers in that country. Unlike the old colonial days, the Project represents more of a collaboration between equal partners. CDC provides most of the infrastructure support, but most the scientific work is undertaken by West Africans. IRBAG has been seeking other similar collaborations to bring the research back to the level of the old days, yet this time as a partner, not a subordinate.

Photographs from left: the old sign of the Institute; IRBAG today in Kindia, Guinea; poster in Cyrillic from the Soviet era research In the Institute.

Leprosy: Global Target Attained

The overall target for the global elimination of leprosy as a public health problem, set ten years ago, has been attained. In 1991, WHO Member States resolved to decrease the level of leprosy in the world by over 90 per cent. This has now been accomplished. To achieve this dramatic reduction of the disease burden, the leprosy elimination effort has increased access to early diagnosis and free cure in communities at risk. The key force in the elimination effort is the Global Alliance for the Elimination of Leprosy. Currently chaired by India, it is spearheaded by the national programmes of major endemic countries, WHO, The Nippon Foundation, the International Federation of Anti-Leprosy Associations, Novartis and the Novartis Foundation for Sustainable Development, Danish International Development Assistance and the World Bank. Created in 1999, this formal Alliance was the natural successor of a little known but highly effective partnership, actively fighting the disease over the last decade.

The victory on the global level must now be reproduced on every national level. Full control of leprosy has eluded mainly six countries: Brazil, India, Madagascar, Mozambique, Myanmar and Nepal. India is maximizing the availability of resources for leprosy through the World Bank and other partners.

Today, diagnosis and treatment of leprosy are easy. Essential work is being carried out to integrate leprosy services into existing general health services. This is especially important for communities at risk of the disease, which are often the poorest of the poor and under-served. Treatment with multidrug therapy is highly effective. It stops transmission of the disease starting with the first dose and prevents disabilities. Over the past 15 years, about 11 million leprosy patients have been cured with this treatment. Multidrug therapy consists of three drugs, which need to be taken by the patient for 6 or 12 months, depending on the severity of the disease. Novartis offers strong support through WHO in the form of free multidrug therapy drugs until at least the end of 2005, which would cure between 2.5 million and 2.8 million patients during the intervening period.