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Most Ebola Patients in the U.S. Survive. Half in Africa Die. Why Are We Letting This Happen?

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This week’s news on Ebola should make you breathe a sigh of relief—and seethe with anger.

The news is the recovery of Amber Vinson, the nurse who got Ebola while treating Thomas Duncan at Texas Presbyterian Hospital in Dallas. She left Emory University Hospital on Tuesday, free of the virus and on her way back to a normal life. The announcement came less than a week after Vinson’s colleague, Nina Pham, was discharged from the National Institutes of Health hospital in Bethesda, Maryland. Pham was in such good shape that she got to visit the White House and give the president a hug.

It’s become a familiar ritual—the Ebola patient leaving a U.S. hospital, alive and well. But the medical feat behind those scenes is among the more under-appreciated developments in this whole saga. The early public health failures, like the improper protocols at Texas Presbyterian and allowing Vinson to board a commercial flight when she had a mild fever, have gotten tons of attention. The successes have not, even though they are easy to catalog.

So far, nine people have received treatment for the disease in American hospitals. Seven have fully recovered. One, Craig Spencer, is undergoing treatment at Bellevue Hospital in New York City. The one patient who died was Duncan and we have a pretty good idea of why that happened. Physicians misdiagnosed his ailment when he first showed up with symptoms. It was only upon his return to the hospital, several days later, they recognized a case of Ebola—and, by then, the disease had progressed. He didn’t simply have a fever. He was vomiting and had diarrhea. 

When patients get an early diagnosis, they have a better chance of responding to the various therapies now available. Those include experimental anti-viral drugs, like ZMapp, and blood transfusions from Ebola survivors that contain antibodies to the virus. The treatments also include more mundane (but absolutely essential) medication to help restore lost fluids and to keep electrolyte levels steady, sustaining patients for long enough to let their immune systems overcome the virus. (Julia Belluz of Vox has written a terrific explanation of the treatments and how they work, if you want to read one.)

The relatively high survival rate of U.S. patients so far could reflect a bunch of factors, like age or the small sample size. That is one reason not to get carried away and assume the standard regimen can save all patients. It can't. But physicians and public health experts say it should be able to save most of them. “An Ebola diagnosis need not be a death sentence,” Paul Farmer, an infectious disease specialist at Harvard, wrote in an influential essay for the London Review of Books. “If patients are promptly diagnosed and receive aggressive supportive care—including fluid resuscitation, electrolyte replacement and blood products—the great majority, as many as 90 percent should survive.”

The survival rate in West Africa has been a lot lower than 90 percent. That’s one reason the scale of suffering there is so much larger—and, going forward, scarier. As of Wednesday, more than 4,900 people had already died from Ebola in West Africa, out of more than 10,100 likely cases, according to the official tally from the U.S. Centers for Disease Control and Prevention. Those numbers are consistent with the historic survival rates, based on previous but more limited outbreaks.

The higher death rate has a relatively simple explanation, one familiar to anybody who has studied health disparities around the world. Health care facilities in the affected countries lack what Farmer has identified as the four S’s: Staff, stuff, space and systems. Except in the most developed areas, the clinics and hospitals don’t have access to even routine medications, common to any American emergency room, let alone newfangled medicines like ZMapp. They may also lack the standard diagnostic tools necessary to adjust treatments. “Right now, many [Ebola treatment units overseas] are not monitoring electrolytes including sodium, potassium, and calcium that are essential to deliver accurate and adequate care,” says Charles van der Horst, an infectious disease specialist at the University of North Carolina.

Of course, even those facilities with the right drugs lack supply and capacity to handle the patient load. Personnel shortages are common—and, in some places, getting worse because the healthcare workers, lacking proper equipment to protect themselves, keep getting sick. As Belluz explains:

The doctors who worked on the American Ebola patients at Emory University in Atlanta pointed out ‘intensive one to one nursing care was necessary around the clock.’ That patients were monitored ‘continuously and this level of nursing care allowed for rapid response to clinical changes’ was a matter of life or death.

This kind of 24/7 access is simply impossible in West Africa. Consider the fact that there are 245 doctors per 100,000 U.S. population. In Liberia, the number is 1.4; in Sierra Leone, it’s 2.2; and in Guinea, it’s 10.

It’s easy to become despondent about what’s happening in West Africa, when, in fact, there’s real reason for hope. On Wednesday, the World Health Organization announced that the spread of the disease in Liberia may be slowing: Week-to-week reports of new diagnoses are down by 25 percent. Anecdotal reports of progress are also becoming more common, usually because aid workers report they’ve built more trust among locals and spread the word about the importance of early diagnosis and treatment—and, for those cases when treatment doesn’t work, proper burial of the dead. Funeral rites, which in many regions involve touching the body, have been a major source of new infection.

WHO officials warn that they’ve seen progress containing before, only to see the disease spread elsewhere. The latest projections from David Fisman and Ashleigh Tuite, from the University of Toronto, suggest that the epidemic in Africa will peak in 2015 and subside after that, claiming between 100,000 and 150,000 lives. (Those are reported cases only; some experts think the real numbers are as much as two-and-a-half times higher.) But early and effective interventions can reduce that toll, as existing interventions already have. The best hope is a vaccine, versions of which are supposed to be field tested next year. But simply getting more staff and supplies to these countries, so that they can follow the standard protocols, would also make a big difference.

Health care facilities in the affected countries lack what Paul Farmer has identified as the four S’s: Staff, stuff, space and systems.

"If [Fisman’s] and Tuite’s model is correct, we have some room for hope amid the global angst,” Melinda Moore, an infectious disease and public health expert at the Rand Corporation, told me via e-mail. “Exponential growth of the epidemic is scary, but the opportunity for exponential impact of timely interventions—any and all interventions that limit transmission-raises hope and should be our clarion call to double down now.” 

This helps explain why so many officials and public health experts are wary of steps like travel bans and quarantines—and determined not to slow the flow of aid to West Africa. They have the tools to contain the disease here and hospitals have the capability to treat the few cases that will inevitably appear. Africa doesn’t. And as long as the disease spreads there, it will wreak havoc, undermining regional stability and potentially creating a chronic medical menace for the entire world. “I think the best way to think of this is that if your neighbor's house is on fire, you can expect sparks to land on your roof,” says Fisman. “It's a highly connected world we live in.  The best way to deal with the sparks is to put out the fire, not to focus on the sparks.”

Timely, appropriate medical care can beat Ebola in many if not most cases. It could save thousands, tens of thousands, maybe even hundreds of thousands of lives in Africa—if only the developed world would commit to providing it.