Opinion | The State of Infectious Disease Control in Africa

In part 3 of this exclusive video interview, MedPage Today‘s editor-in-chief Jeremy Faust, MD, talks with Craig Spencer, MD, MPH, of Brown University in Providence, Rhode Island, about the 10-year anniversary of his treatment for Ebola at Bellevue Hospital in New York City.

Click here to watch part 1 and part 2.

The following is a transcript of their remarks:

Faust: For most people who haven’t heard you speak before, they won’t realize that, to the best of my knowledge, this is the interview where I’ve somehow made you talk about yourself, which you usually don’t do. You usually quickly pivot to talking about the patients that you flew over to take care of and the people who really are at the highest risk.

Tell me about, just so people know, what your concerns are with how resources are allocated. For the people who haven’t — unlike me, I’ve heard you say these words a hundred times — but the usual Craig Spencer interview is about those places and those people, isn’t it?

Spencer: Yeah. Because I think their story — there are, one, tens of thousands of those stories and one of mine. So I think just from a quantitative place they’re more powerful and more impactful and more important. I think qualitatively, like look, my story had a lot of media attention. But again, I had a test result in hours. I took care of probably 30 to 40 patients every day in West Africa, and there were probably 30 to 40 of some of the best medical providers at Bellevue Hospital on call to contribute to my care at any point. I had access to everything that I could possibly need, and the hundreds of patients that I saw, the tens of thousands of patients that we saw across West Africa, very often did not. And I know that that is truly the difference between life and death for a lot of folks.

And again, as I’ve said over and over, I can be both grateful for the care and the resources that I received, but also feel guilty about the fact that people around the world aren’t able to receive the same thing.

And it’s not like I or other people are asking for everyone to have access to the newest cutting-edge chemotherapeutic medication that just rolled off the shelves yesterday. A lot of the time it is, what can we do to get some of the most basic interventions to people that can have such a dramatic impact on people’s ability to live or die?

We’ve seen right now in Rwanda, the case fatality rate is about 22%. So about a quarter of people that are getting Marburg are dying. That’s still really high. It’s not any odds that I would want to take, but I think that’s actually probably the lowest case fatality rate that’s ever been measured.

In one of the first outbreaks of Marburg in 1967, it was around the same spot. And subsequently there’s been 18 outbreaks, a lot of them in places where resources are really limited and your mortality has been as high as up 88%. We are now like 60 years-ish later after discovering Marburg. The type of clinical care that they were able to provide in 1967 undoubtedly was not incredibly great in high-tech.

But what we’re seeing now is that around 60 years later, Rwanda is still able to provide that similar type of care. It doesn’t have to be incredibly high-tech, it doesn’t have to have all the bells and whistles. It needs some basics. And they were able to do that very well, and we’ve been able to see the impact. There’s been a dramatic decline in the number of people that are dying.

So I, and many others I think in a much better way, are basically trying to make everyone else aware and advocating for access to some of the most basic things that people need in outbreaks, that people need at baseline just to stay healthy. It not only helps in those scenarios to keep people healthy, to stop outbreaks at their source; but in terms of health security globally, it makes us all safer.

The fact that I would presume — I know your readers know about Marburg because you’ve written about it — but most people have no idea. They don’t know that it’s going on, and that’s great. They can go about the holidays, the election season, and not have to worry about this other thing happening in another place and whether it will impact them, infect them.

The downside of that is that people won’t realize how successful and how great this was and how important it was that the U.S. as a country and the international community over the past 3 decades since the Rwandan genocide has invested in all of the support structures in building up a health system, doing all these things around training and preparedness that have helped make Rwanda into a health system stand-out in the region, and helped it lead its own response to this outbreak.

It didn’t need us, it didn’t need people like me. They could do it by themselves with the right support, and their success keeps us all safer. It also means that people are not as aware of it as they otherwise would have been had they not been so successful.

Faust: You just answered most of my second to last question, which is there’s probably nobody better positioned to say why the response to Marburg in Rwanda has gone as well as it has than you. Can you just say a little bit more about how the physicians and public health officials on the ground in Rwanda have been able to be so successful in controlling this outbreak?

Spencer: Yeah. I’ve been lucky in that I know a lot of people working on the frontline of the outbreak, and I’ve worked a lot in the region. In Rwanda, but also in DR [Democratic Republic of] Congo and in neighboring Burundi. So I know a lot about what capacity exists and what happens when you don’t have that capacity.

But the ability to respond to an outbreak, to do it well, does not start the moment that a case is found and an outbreak is declared. It starts well in advance. And so we know that over the past decade plus, Rwanda has been building up a very strong emergency medicine cohort of providers, nurses, doctors, working with tertiary hospitals to strengthen their capacity. You and I know a lot of folks that have either worked there or have trained there and helped build up an emergency medicine residency, for example.

I mean, it’s that type of health system strengthening that happens not just at the emergency medicine level, not just at one hospital, but at different specialty levels, at different hospitals around the country and not just the capital, that provide those really strong bones for how you’re going to do a response. It involves having interactions with international folks and experts, of which Rwanda does very, very well, but also has its own kind of homegrown internal resources for training epidemiologists and for doing data monitoring.

We saw over the past couple years during COVID [that] Rwanda was really out on the front in terms of how it was able to manage the COVID pandemic. They were excellent at getting people vaccinated. They’ve been thinking about novel ways to do things around assistance throughout the country even before COVID.

So you have all these things that went into what happened before the first case of Marburg was even encountered or described.

And then once that happened, there was a span of a couple weeks between what appears to be the first case and the actual identification of the outbreak, which sounds like a long time, but historically is actually really, really short. The first Ebola case that caused the 2014 to 2016 outbreak probably occurred somewhere around December of 2013, but wasn’t identified for months later. So this is pretty normal in these outbreaks. In Rwanda, they have great diagnostic capacity.

A lot of this built up over the past couple years in responding to COVID, using some of the same machines that we use to diagnose COVID. PCR can be used for Marburg and other viruses. So you had a lot of the resources already in place. And then once this outbreak was identified, the Rwandan Ministry of Health, along with international support, was able to quickly ramp up testing, contact tracing, reached out to groups like the nonprofit Sabin [Vaccine] Institute in D.C. to say, “Hey, I know that you have a vaccine candidate in phase II trials now. We would love if you could find a way to get some of that in-country.”

And 8 days later, in what is truly an unprecedented timeframe for global health response, you had 700 doses of this investigational vaccine in-country being injected into the arms of frontline healthcare workers. A few days after that, you had a thousand doses coming, and now we know there’s another thousand doses coming in addition to monoclonal antibodies and other investigational treatments.

There are hiccups, there are things that didn’t go right. There are issues around early transparency and communication. These outbreaks are really, really, really difficult to manage and they take a lot of time. But on the whole, I’ve been really impressed with how well the Rwandan Ministry of Health has handled this, has thought about ethical questions, and has done everything it can to keep particularly the healthcare providers safe, while also reassuring the rest of the world that they have this under control.

Faust: Thank you for that update.

My last question for you is, you have occasionally said to me, “Oh, sorry, I had a little lapse there. That’s Ebola brain.” And I want to know, is Ebola brain a thing or are you just now in your 40s, Craig?

Spencer: Both, I guess. I will blame the former for the latter, but if I’m doing that in 40 years, well then I’m lucky that I’m still alive.

Look, we know that just like for COVID — I think anyone that has followed your newsletters and your reporting and things you’ve written about knows that there’s a thing called long COVID and that it exists and that a subset of people who get COVID can have either mild long-term or maybe severely debilitating long-term symptoms. And it’s not all people, but it’s some people.

With Ebola, we know that a lot of people, a lot of survivors continue to have long-term symptoms, whether it is around mental health, around depression, or around physical health. And it may be continued fatigue, weakness, bone pain, et cetera. We’ve heard a lot about brain fog over the past couple years with COVID. This undoubtedly exists not only for Ebola, but for other infectious diseases that cause long-term sequela.

For me, the one thing that I think I’ve noticed most durably over the past decade is not a change in my memory or my ability to practice as a provider or public health person, but something even smaller and more granular than that, which is ability to remember names, even for folks and for people that I’ve had deep contacts with in the past. That’s really the only thing that I’ve noticed. So if I’m using it as an excuse for other things, maybe call me on it. But if, despite being a good friend of mine, the next time I see you I look in your face and say, “Who are you?” Well then, maybe slap me and set me straight.

But I think that’s really the only thing. But again, in that case, I’m quite lucky compared to a lot of other people in that I got out of the hospital in November of 2014, so November 11, 2014. Less than a year later, I committed myself to and ultimately did run the New York City Marathon as kind of a way to both be an overachieving emergency room doctor addicted to adrenaline and other high endurance sports, but that was just kind of a way for me to try to put myself back on a mental health and physical health path.

But I recognized that I was in a place at that time where that kind of luxury was not necessarily available to all of the other survivors.

Faust: Craig, thank you so much for sharing your advocacy and your story and for being alive and highlighting all the good work that is going on in this space. Also, congratulations on the 10 year anniversary of leaving Bellevue Hospital.

Spencer: Thanks, Jeremy.

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