In part 2 of our Q&A with Fair, we talk about the challenges ahead in the fight against Ebola in the Democratic Republic of the Congo.
Fighting Ebola on the ground in the Democratic Republic of the Congo (DRC), Joseph Fair, PhD, MSPH, has dedicated his life to outbreak response.
A virologist and outbreak responder, Fair is a senior fellow at The Scowcroft Institute at the George Bush School of International Affairs, Texas A&M University, who is currently on the ground in the DRC where the second-largest Ebola outbreak in history is still raging.
In part 1 of our Q&A with Fair, we discussed his background, education, and experience, and also how the outbreak response to the current Ebola outbreak in the DRC differs from traditional disaster response. In part 2 of our Q&A with Fair, we talk about the challenges ahead in the fight against Ebola in the DRC.
Contagion®: In your opinion, what are the major challenges still ahead in the fight against Ebola?
Dr. Fair: he greatest challenges in my opinion are getting to the people that need us the most and convincing them that we are here to help and not do more harm. Fear spread by conspiracy theories still prevail, so our public health messaging has to be improved and we need to listen to our hosts in DRC to determine how best to craft those messages. Survivors are key in getting the message across to their friends and neighbors, as are local religious institutions. These are locals that will stay in the community after this is all done and will remain there as guardians of institutional memory. They know the virus is real, that we are not here to kill them at the behest of their government, speak the local languages, and are trusted within their communities.
Security is also certainly an issue, but not nearly as much as it is being made out to be. I spent five months in the Beni/Mangina/Makeke areas, and the violence is real, but this is not the first public health response to happen in a conflict area. The main problem caused by security threats is its effects on contact tracing and tracking down new cases, isolating them, and implementing ring vaccination.
What needs to be done that isn’t in order to slow the spread of the virus?
Training and utilizing survivors of the disease as more than research subjects. NGOs and local/national government need to focus strongly on the recruitment of Ebola survivors to work as Community Liaison Officers. The community has imminent distrust for government and to a lesser extent, NGOs. Survivors are their only tangible proof that the conspiracies are not true, and that your life can be saved if you report early for treatment. Only when the population reaches this conclusion themselves and seeks treatment on their own, will the epidemic stop. They should man road checkpoints and markets, as well as be used in community outreach. They are local and speak the language. If we provide them with salaries, transport, and automatically enroll them in survivor studies, if they so want, it would do much to win the trust of the local community. You have a virtual army of survivors from this outbreak, as well as from nearby Isiro; they will be the key to rebuilding these communities after we are all gone, and this approach vastly decreases their own stigmatization.
What is your message to clinicians in the States regarding Ebola in the DRC?
Ebola is exciting and everyone wants to publish in the NEJM, but I had a colleague who recently went home with her child who had a norovirus infection. Instead of actually listening to her and that she worked at an Embassy thousands of miles away from the outbreak, they put her and her son in full isolation, dressed in full PPE, and traumatized them both over a 10-hour period of time. I had the same experience when coming back to Orange County in 2015. I would urge clinicians to be astute and ready, but don’t be in a hurry to find a zebra when its likely a horse. Listen to your patient’s history and consult the CDC and actual specialists before traumatizing your patient, not to mention costing them thousands of dollars of unneeded expenses. This only encourages people that need help to not seek it out of fear of being quarantined for giardia, norovirus, or any number of things you would get here on a normal day. If you are coming from outbreak zone, that is a different story, but one you should take the time to listen to and note.
Have you had any brushes with violence while in the DRC? What is your take on the reports of killings and kidnappings in the outbreak zones?
Nearly anyone who has ever worked in DRC has had bushes with violence at some point. This is my fifth Ebola outbreak and my fourth in DRC. I have definitely experienced violence during that time, especially in Isiro where myself and colleagues from CDC and Public Health Canada were surrounded by a machete wielding mob. I arrived in Beni on August 7th, 2018 and have spent around five months there since the outbreak started. The real danger is to local employees of the response. Those incidents of killing and kidnappings happen every day and continue to do so, but to a lesser extent. Westerners and frankly, non-Africans, are rarely targeted out of fear of triggering a robust military response. From historical precedence, rebel groups rarely fear reprisals from killing or kidnapping locals or other Africans. My good friend Richard from WHO is a great example; he was outright executed while doing his work as an epidemiologist. There is a danger to everyone, especially when you come in with new iPhone and driving new Land Cruisers, but the real danger is to our local colleagues who face the worst conditions on a daily basis.
I also personally think that if your main concern is being safe then should probably choose another profession or stay back in the US and help crunch the data coming out of the field. We that choose to do this accept that there is a risk to our lives. Ironically, you are far more at risk of getting shot in the USA than in an Eastern DRC warzone.
What is your stance on the outbreak receiving the status of Public Health Emergency of International Concern from the WHO?
All I can say is that is has made absolutely zero difference on the ground and in regard to the outbreak itself. It may have released some funds, but it mostly made the proponents of the GHSA happy. It has done nothing to alleviate field conditions, nor has the “innovative” funding mechanisms that were developed after the West African Ebola outbreak. Dr. Tedros received a lot of criticism, especially from the US, for not declaring a PHEIC earlier but I fully support his course of action.
Health workers have been particularly vulnerable to infection during this outbreak despite the use of the Merck vaccine. Why is this occurring?
First, it is because healthcare workers are always disproportionately affected as they are the frontline in this war (and every other epidemic of infectious disease). The vaccine is in short supply and healthcare workers are prioritized, but that was slow in getting fully up and running. Healthcare workers that died after being vaccinated were likely either infected just before being vaccinated or just after, and like yellow fever vaccine, this vaccine takes 10-12 days to become protective. Infection Prevention and Control or IPC is still the main the weapon in preventing healthcare workers from being infected and from spreading the disease amongst their patients. IPC is difficult when you don’t have gloves, masks, PPE, and disinfectants readily at hand. Even when you do have those, you need to know how to use them correctly and this takes time to rollout the training and for it to become institutionalized and strictly adhered to.
Can you speak to some of the successes of the response to this outbreak?
I would consider the rollout of the vaccines and therapeutics major successes in this outbreak. We never had these tools at our disposal before now. Conducting clinical trials in this setting is not easy by any stretch and the fact that WHO, MSF, IMC and others were able to come together to do so despite the circumstances is astounding.
Secondly, the Africa CDC has played and continues to play a major role in this outbreak and is evolving into a role that used to be filled by the US CDC. This is key for the development of Africa and they have done an amazing job. They will continue to evolve into a center of excellence and will be able to response far faster to this and future outbreaks than we could ever hope to do. I applaud their leadership and their fearless army of field personnel.
This outbreak and the past few have shown the importance of investing in programs like the CDC’s field epidemiology training programs (FETPs). They are the new generation of virus hunters and are a literal army of field personnel willing to go where others are afraid to do so and stop the virus before it spreads further.
Lastly, It has been refreshing to see the press focus this time on local outbreak responders that do this for a living and are not professors here for a few weeks to ship samples back to the USA or Europe to make a name for themselves or be highlighted in the press. These people risk their lives every day and it is insulting to read about someone who went on field vacation for a few weeks praised as heroes and saviors like happened in 2015.
What is your reaction to the flurry of news regarding new Ebola therapeutics?
I am happy the work is being recognized and the significant progress that has been made. I would argue that it is equally if not more important to focus on the fact that the work entailed in developing those drugs occurred over decades of collaboration and field work. At least in the US, it is difficult to get long term funding for the developing world due to the risks involved and because it doesn’t result in immediate returns. Professors Muyembe and Piot have dedicated much of their lives to the work and it is great to see it paying off in terms of lives saved.
For the most recent Ebola case counts, check out the Contagion® Outbreak Monitor.