Don't Kiss the Cadaver

Since 1976, Africa has reported over 2,000 cases of Ebola. Lessons were learned -- it's now up to Guinea to remember them.

Despite millions of dollars in research on vaccines and treatments, the deadly and frightening Ebola virus is best tackled today the same way it was during its first epidemic in 1976: With soap, clean water, protective gear, and quarantine. In fact, the care, treatment, and control of the virus is most effective when handled the way American physicians dealt with the 1918 influenza pandemic almost 100 years ago.

The outbreak now unfolding in Guinea -- the first in West Africa in 20 years -- has also spilled over into neighboring Liberia and possibly Sierra Leone. With 122 cases and 78 deaths reported to date, the epidemic has officially been declared a "regional threat."* The West African region shares a vast tropical rain forest rife with virus-harboring animals, including rodents, bats, and chimpanzees.

The Ebola hemorrhagic disease is terrifying, as the virus punches microscopic holes in the endothelial lining of blood veins, vessels, and capillaries, causing blood to leak from its normal pipelines coursing through the body. Within hours, the punctures enlarge, the leaking turns into a flood, and blood pours into the intestines, bowels, and respiratory channels. As the victims become feverish -- raging in pain and hallucinations -- their tears drip red with blood. The crimson liquid flows from their noses, ears, bowels, bladders, mouths, while old wounds reopen all over their bodies. The deterioration is swift, transpiring from infection to death typically within five days. And Ebola is spread, via the infected body fluids, to attendant family members, health-care workers, and funeral preparers.

In 1995, when I was reporting on the Ebola epidemic in Kikwit, Zaire (now the Democratic Republic of the Congo), the disease struck terror across the community of some 600,000 people, many of whom would wail through the pitch dark night the names of the virus's victims. The dread was compounded by the inability of doctors and nurses in the region's clinics to protect themselves. As medical workers contracted the infection and fled their posts or succumbed to Ebola, the Kikwit community wondered, "What dreaded thing is this, that even the doctors cannot protect themselves?"

When all was said and done, there were 160 confirmed or suspected cases of the virus and 121 deaths throughout the country -- Kikwit was home to 138 of these people.

Thanks to the bravery and sound scientific work of the international response teams that responded to the original 1976 epidemic in Yambuku, Zaire, and the subsequent outbreak in Kikwit, the governments of Guinea, Liberia, and Sierra Leone can today make smart decisions to stop the virus from spreading and save lives. African communities no longer need to live in horror and dread, fearful of the lurking virus. Nor must they depend on nonexistent miracle drugs and vaccines from the outside wealthier world.

* * *

On behalf of the World Health Organization in 1976, Karl Johnson, a trout-fishing epidemiologist from the American Rockies, led a hastily assembled international team of African, European, and American scientists to respond to what was then a completely mysterious epidemic unfolding in one of the most remote locations in the world. The brutal Mobutu Sese Seko regime that then ruled Zaire spent nary a franc on the far-flung rural villages of what was once the Belgian Congo, built no roads or airports, and gave only lip service to the country's own medical and public health infrastructure. Johnson's team of disease cowboys was largely on its own to find means of transport, to discover the epidemic's cause, and to figure out how to stop it. Worse, it was rumored that another outbreak of the same mysterious microbe was unfolding to Zaire's north, in an even more remote southern corner of Sudan.

As I described in detail in my first book, The Coming Plague, Karl Johnson's 1976 team had no technological tools at their disposal -- vaccines, cures, genetic screening, or rapid diagnostics. One team member, American Joe McCormick, was dispatched with an old Land Rover, some food, and water to drive all the way from Zaire's capital city of Kinshasa to southern Sudan, guided by little more than old Belgian maps and a compass. His "roads" proved to be nothing but Congo river rafts and footpaths, which formed a commerce network of trade between villagers who spoke no English, very little French, and divergent Bantu dialects.

Johnson deployed a Belgian medical duo -- one of which was the now-famous Peter Piot -- to the Zairois village of Yambuku, thought to be the epicenter of the mysterious outbreak. The Belgians discovered that the entire epidemic was spawned by a Catholic missionary outpost so poorly supplied that it reused the same five hypodermic syringes for everything from vaccines to anesthetics, unwittingly spreading the Ebola virus with each injection.

Up in Nzara, Sudan, McCormick found that humans there were also responsible for spreading the virus, as families washed the bodies of their loved ones and swathed them for burial, infecting themselves with virus-laden blood in the process.

In my second book, Betrayal of Trust, I detailed my observations of the 1995 Kikwit epidemic. Though nearly 20 years had passed since Karl Johnson's intrepid team faced Ebola in Yambuku and Nzara, the tool kit was little improved: There was still no vaccine, treatment, cure, diagnostic, or knowledge of where the virus came from.

Once again an international scientific and medical team was assembled, led by the World Health Organization's American-born David Heymann. The Dutch chapter of Médecins Sans Frontières (MSF) deployed a tiny team to help in Kikwit's largest hospital; Zimbabwe and South Africa sent animal experts to detect the source of the mysterious virus; and local Zairois scientists and medical students spread out across the town in search of clues to the epidemic's origin and solution.

* * *

Since 1976, some 2,200 cases of Ebola have been confirmed in outbreaks spread across equatorial Africa, from its far west to Gulu, Uganda, in the east. Of those, 1,500 were fatal, with mortality rates as high as 95 percent during the Yambuku and Kikwit epidemics, and as low as 35 percent in the more recent outbreaks in Uganda, Sudan, and Congo.

It is not clear whether the decline in fatality is due to waning virulence in the virus or other factors: Combined cases from 1976 to the present have had a 60 percent mortality rate, making Ebola a highly lethal virus for human beings.

From the Yambuku, Nzara, and Kikwit epidemics, researchers have learned at least seven lessons that can effectively guide responders today in Guinea and its neighboring countries.

First, the index case -- the initial person contaminated with the Ebola virus -- is usually a hunter or villager who recently spent time deep in a tropical forest and came into contact with an animal carrying the virus. In Yambuku, the index case was a hunter; in Kikwit he was a charcoal-maker who spent a week burning wood in the forest to sell in town; in a prior West African outbreak, the index case was a family that killed and ate an ailing chimpanzee. Stopping the spread must include cutting off contact between forest animals and human beings, especially tropical fruit bats that harbor the virus without harm to themselves, and the monkeys and apes that eat the bats or the fruit that they chew on, contracting Ebola in the process.

A broad range of mammals can be infected lethally with Ebola experimentally, demonstrating that the probable bat-host species can pass the virus to dozens of intermediary species, from which humans get infected. There is some evidence that the virus mutates inside monkeys and apes, adapting to become more infectious to primates, including human beings. Guinea's government has wisely issued warnings to its populace: Do not eat bats or monkeys. Moreover, it has banned the trade in wild animal flesh, or so-called "bushmeat" -- measures neighboring Sierra Leone and Liberia would do well to immediately imitate.

The past epidemics indicate that outbreaks in humans are preceded by deaths among forest animals, especially primates, and may be spawned by stress on the bat populations. Across Africa, typically shy bat species pollinate the trees of the rain forests as they nocturnally scour for fruit. As the heat increases in the upper canopies of forests, due to climate change, and as humans increase their logging operations, the bat populations are now under great stress.

When distressed by such environmental changes, animals are more likely to venture near human habitation in search of food and come down from the upper tiers of forests into tree levels filled with predatory monkeys and chimps.

Once in Nzara, McCormick found the rafters of a Sudanese textile warehouse filled with bats. South African virologist Robert Swanepoel found swarms of bats in trees inside Kikwit town, and traces of Ebola in their blood. Even bats found in a cave in Spain carried Ebola. The bats play a vital role in the survival of rain forests: The solution is not elimination of the animals, but of human contact with them.

Third, the bravest interventions, and most essential, are those carried at great personal peril by local Red Cross volunteers. Stopping an Ebola epidemic requires removing ailing individuals from their homes and placing them in isolation quarantine.

Families protest: Who wouldn't? Taking parents from their children, wives from their husbands, babies from their mothers' breasts are all acts that evoke rage and sorrow. But leaving the bleeding patient in the home, to spread the virus to family members, guarantees the epidemic will persist.

In Kikwit, it was obvious that foreigners drew greater outrage than local volunteers, though even Kikwit's brave Red Cross members were sometimes beaten and, sadly, infected as they carried out their sorry duties. The International Red Cross sent teams into Guinea this week -- a measure the organization failed to undertake in the Zaire epidemics. It is essential that local Red Cross volunteers receive full international support, protective gear, and sophisticated training wherever Ebola surfaces.

Fourth, burials must -- despite religious and cultural preferences to the contrary -- be carried out without ceremony, with bodies placed in deep-dug graves to avoid spread within funerals. Traditional practices of touching or kissing the cadaver in open-casket ceremonies must be prohibited.

Fifth, though it is rare, the Ebola virus can be spread through the air between people. Every health worker, Red Cross volunteer, gravedigger, and outbreak investigator must wear protective face masks when near an infected animal or individual. Such masks are not routinely available in rural Africa: Even Kinshasa had few in 1995. Among the most important supplies donated by outsiders are protective face masks.

Sixth, MSF now has much experience with Ebola, as teams of the Nobel Prize-winning organization's medical and humanitarian response personnel have been engaged in nearly every Ebola outbreak since Kikwit.

I arrived in Kikwit within hours of the small MSF team led by Dutch physician Barbara Kerstiens and watched as they swiftly erected a rainwater catchment, electrical generators, and basic barrier protections for quarantine in and around the primary hospital. Before MSF arrived, Ebola spread like wildfire among doctors, nurses, lab techs, and orderlies -- none of whom had soap, running water, electricity, latex gloves, masks, or protective gowns.

MSF is now on the ground in Guinea, no doubt bringing safe infection control to local hospitals. They need support -- not in the form of exotic disease spacesuits and $300,000 mobile laboratories, but with supplies of soap, antiseptics, water filters, generators, and basic protective gear.

Seventh, forget about high-tech solutions, "cures," and vaccines: They do not exist. Following 9/11 and the 2001 anthrax attacks, the U.S. Congress ordered the U.S. Centers for Disease Control and Prevention to designate a list of possible bioterrorist germs, and under Project BioShield it financed R&D on treatments and vaccines. Though Ebola was on that list, and in 2011 alone garnered $5.4 million in research funds, a list of exotic treatments for the disease, including monoclonal antibodies and genetic manipulation, have never left the lab bench.

Tests of Ugandan Ebola survivors show that their bodies make antibodies against the virus that persist in their bloodstreams for many years, but researchers have had little luck in concocting an Ebola vaccine or proven antisera. And private-sector vaccine developers see no commercial basis for Ebola products given the rarity of outbreaks and the impoverished status of those most likely to need immunization.

* * *

In early March, I had dinner in London with Peter Piot, who now runs the London School of Hygiene and Tropical Medicine. He had just returned from Yambuku. It was the first time he had been there since 1976, and he'd found the visit a shattering experience. The local Catholic hospital was even less equipped in 2014 than it had been in 1976, and the villagers live more desperate, impoverished lives today than they did 38 years ago. "It's terrible, just terrible," Piot repeatedly told me.

Three years after the 1995 Kikwit outbreak, I too returned to the strange site of the epidemic I had experienced, making similar, sorrowful discoveries. Mobutu died not long after the Ebola epidemic, leaving the national treasuries literally empty: He and his clan had looted every bar of gold and piece of foreign currency that once sat in vaults, supposedly guaranteeing the "validity" of Zaire's currency. Civil war broke out, elements of which still smolder across the country in 2014.

To get to Kikwit in 1998 I had to buy a "seat" on a stolen military transport plane, strapping myself atop a large wooden crate inside the cargo hold. The Kikwit landing strip had been a groomed soccer field just three years prior. By the time I stepped off the plane, the grooming had ceased and the cargo plane bumped across tall weeds that were whacked by the plane's propellers.

As I proceeded to the hospital -- which had been full of dying Ebola patients in 1995 -- I spotted the ambulance that the German government donated during the epidemic. It was transformed into the local governor's private limousine.

At the hospital entry I spied a familiar sight -- a large pit filled with burning logs, over which a steel tripod held a cauldron of boiling water used for sterilizing syringes and equipment. The generators MSF had brought to power sterilizing autoclaves? Long gone, looted by military thugs along with the X-ray machine, doorknobs, microscopes, toilets, and every other item thought to have a resale value.

Over bowls of rice, I had a farewell lunch with one of Kikwit's surviving nurses -- a young man who contracted Ebola on the job and was among the lucky 5 percent who outlived the damned microbe. He told me that every day was greeted with dread, as soap, water, gloves, and masks were no longer available.

As he spoke, he trembled with fear. I reached into my camera bag and pulled out two small bottles of Purell hand sanitizer. The nurse's eyes popped, he snatched the bottles, and hid them in his pants. Scanning the dining room to see if any colleagues had spied the precious cleanser, the nurse feigned nonchalance and sauntered to his staff locker, hiding the Purell inside.

As I prepared to leave the Kikwit hospital, he walked up beside me, smiled, and whispered: "Tonight I will finally sleep."

*Update, March 31, 2014: This article has been updated to reflect a more recent death toll and the confirmation of cases of Ebola in Liberia. (Return to reading.)



Fracking's Known Unknowns

If the United States is going to help Western allies neutralize Russia's energy stranglehold, it needs to get to the root of why so many people fear fracking.

With Russia menacing Ukraine and Europe with its natural gas heft, the cry has gone out from British Prime Minister David Cameron, the Wall Street Journal, and even (implicitly) U.S. President Barack Obama: more fracking! If only the EU would stop importing a third of its natural gas from Russia, the argument goes, it would be easier to impose sterner sanctions and go beyond grandly booting Russia from the G-8. Fracking sounds like a simple and smart solution. Not only can the United States export liquefied shale gas to Europe, but Europe can also help itself diversify by embracing a technology that taps homegrown reserves. "You cannot just rely on other people's energy," Obama reportedly told EU leaders.

The trouble, of course, is that much of Europe, especially the western half, doesn't want to frack. France (which has considerable reserves) has banned it, Germany has effectively done the same, and Cameron's enthusiasm has been slowed in the United Kingdom by not-in-my-backyard environmental protests. As Conservative MP Nick Herbert (who's not reflexively against fracking) put it last year, fracking has sparked a "fear of the unknown."

Ah, those pesky known unknowns! Herbert actually nailed the problem. So, here's a way to help spread fracking: Banish the unknowns. There is still so much uncertainty and hence controversy surrounding fracking, even in the shale-crazed United States, that other countries inevitably have qualms about adopting the technology even as they hanker for its benefits. Fracking, aka hydraulic fracturing, involves shooting water, sand, and chemicals beneath the earth to break rock and extract oil or gas. People living in shale-rich areas have raised concerns about air pollution, potential groundwater contamination, and even earthquakes. Here's Herbert again: "People understand the national arguments about the need for secure and cheap energy, but they don't know how much this is going to damage the local environment." Exactly.

Definitive, comprehensive, objective studies of fracking are needed to help both ourselves and our allies think rationally about fracking and how it stacks up to the alternatives, like renewable energy, nuclear power, coal, or the cheap-gas trough of Vladimir Putin. Alas, such studies are elusive -- and those that exist are quickly challenged by one side or another. As ProPublica has written, "A long-term systematic study of the adverse effects of gas drilling on communities has yet to be undertaken." That's a notable omission, given that shale accounted for one-third of U.S. natural gas production in 2011 and is rising quickly.

Fracking is a complex, multistage procedure that can affect the environment in many ways, each of which deserves careful independent review. From an environmental perspective, the key difference from conventional drilling is the amount of liquid involved. Fracking uses a mix of water, sand, and chemicals to blast rock and extract oil or gas. That liquid, often several million gallons or more per oil or gas well, must be acquired, transported, and used in the frack job. Leftover wastewater must be stored and then disposed of, usually by injection into an underground formation where it is supposed to remain in perpetuity. (Recycling of this excess liquid is still in its infancy.)

If a spill occurs or the liquid seeps into the ground during any of these steps, that's a problem. Strange things can happen. An official who oversees groundwater in part of West Texas told me for a 2013 Texas Tribune article I co-wrote that in a few instances, salty water from underground has unexpectedly shot up out of abandoned old oil wells. What he describes is like something out of a sci-fi movie, only real. "They'll be in a field where they are pumping some of these old wells," he said, "and they have an injection in one part of it, and all of a sudden something happens and there's this big leak and it shoots up though the well, and the neighbor's water well starts getting salty." It's basically a mini-geyser of brine.

Other, more typical fracking concerns include air pollution from gas storage or well sites, as chemicals like hydrogen sulfide or benzene are released; methane leaks from natural gas infrastructure; wasteful flaring (i.e., the burning of excess natural gas that comes up with oil); and earthquakes that could be caused in a few areas by the underground disposal of frack water.

How often do things actually go wrong, things like brine shooting out of an old well or earthquakes resulting from underground injections? How many pollutants enter the air, and how dangerous are they? Frankly, we don't know many of the answers. An eight-month investigation by the Center for Public Integrity, InsideClimate News, and the Weather Channel found that in Texas, the top oil- and gas-producing state, the air-monitoring system in a major fracking region known as the Eagle Ford Shale "is so flawed that the state knows almost nothing about the extent of the [air] pollution" in the area.

Fragments of data on fracking do exist. For example, a new study by British and American academics in the journal Marine and Petroleum Geology calculates that 6.3 percent of 8,030 inspected gas wells in Pennsylvania's Marcellus Shale experienced structural problems between 2005 and 2013. That's useful information, but it only takes account of one state and one type of problem (albeit an important one). In Europe, the researchers said, little equivalent public data exists on the structural problems of onshore oil and gas wells. (Because geology can vary substantially from place to place, data from as many areas as possible is needed in the public domain. This geologic variation also means that interested groups are sure to challenge studies as inapplicable to other regions.)

The U.S. Environmental Protection Agency (EPA) expects to complete a study of how fracking impacts water in 2016, two years behind schedule. It will include consolidated information on spills of fracking-related fluid, meaning problems like leaking storage pits and spills from trucks. This is material we need, but even the EPA is finding it hard to pull the data together, according to its latest progress report. For example, in frack-frenzied Texas no database exists on accidents related to hydraulic fracturing. Oil and gas regulators keep data on spills such as the recent Galveston barge collision, but they do not tally chemical spills linked to fracking, according to the EPA report. Wyoming and Colorado, among others, do not break out hydraulic fracturing data on accidents either. An industry website, FracFocus.org, contains some information about fracked wells (unrelated to accidents), but it is partial -- especially as it relates to chemical disclosures -- as well as voluntary and difficult to pull data sets from.

Case studies are needed too, and the EPA is performing some. But this is hard. For one thing, the geology is complex, and fracking cannot be studied up close without industry cooperation.* Both Ohio State University and the University of Tennessee have courted controversy by considering contracting with -- and accepting fees from -- drilling companies that would work on university lands.

The influence of oil and gas money has a long reach into academic institutes, not to mention state government. "'Frackademia' has become the preferred term to describe the new partnerships forming between academia and the fracking industry," Cary Nelson, a professor at the University of Illinois, Urbana-Champaign, wrote in the Times Higher Education last year. (Similarly, the industry challenges studies in which academics are perceived to have an environmentalist bias.) When I covered oil and gas in Texas between 2010 and 2013, one of the hot topics was the amount of water used in fracking. Fracking can use 4 million to 6 million gallons of water per well, or more, so at a time when drought was hitting Texas hard, that naturally came under scrutiny. For journalists, it was frustrating that the major study on the subject (performed by University of Texas researchers with the imprimatur of the state government's water board) was funded by an oil and gas association. The 2013 study found that less than 1 percent of annual Texas water use went into fracking. But a subsequent San Antonio Express-News analysis found that the figures for the Eagle Ford Shale, the major new formation in Texas, "far outpace[d]" certain estimates in the industry-funded study.

The benefits of fracking are clear. It has been a giant step toward energy independence for the United States, and it can be for the rest of the world. Everyone wants the jobs it brings, the wealth and tax revenues it produces, and the energy it provides. It's cleaner-burning than coal, though the dynamic between those two fuels is complex. But it's time for an honest, levelheaded conversation involving scientists, the federal and state governments, and the public about what we know and what we don't know about its environmental impacts. We need to collect data and make it available, and we need to figure out how to get answers for the many remaining unknowns, so that countries can decide how to regulate fracking or indeed whether to allow it. Businesses hate uncertainty, as the saying goes -- so ending these environmental uncertainties might just help the oil and gas industry by allowing it to make a clear case to the public in the United States and abroad.

This will require cooperation on all sides and, of course, money. In the ideal world, the public and disinterested groups would provide funding. Another suggestion comes from Nelson, the University of Illinois, Urbana-Champaign, professor, who has recommended a levy on drilling companies and the creation of a pool of independent resources for study grants.

"But there is no time!" the cries ring out as the Russian wolf stands on the doorstep, baying. The clock is ticking, yes, but it's also true that homegrown shale gas in Europe cannot fill the gap in the near term; it may take a decade for it to be extracted in meaningful quantities. That's plenty of time for study and analysis to lay the groundwork for long-term development of an extraordinary resource. My great hope is to get beyond the juvenile conversation we're having now -- the echoes of which are heard worldwide -- in which environmentalists holler loosely, "Fracking contaminates groundwater!" To which the industry -- taking the term "fracking" to mean the specific process of rock-breaking, perhaps the least of the risks -- responds, "No, it doesn't!"

Even with more information and continued pressure from Russia, Western Europe still may not be tempted by fracking. At its core, fracking is a mini-industrial operation that often takes place near homes. If the wealthy can avoid it, they will, because the disruption in their backyards will not be worth it. There are also other barriers to shale gas development in Europe, such as the cost of drilling, Europe's relatively high population density, and the ownership structure of mineral rights, as my friend Russell Gold of the Wall Street Journal (and author of the forthcoming fracking tome The Boom) recently explained. The quality of European shales are still uncertain, though France, Poland, Norway, and the Netherlands, as well as Ukraine, are among the countries believed to have substantial reserves. But if Britain or Poland wants to proceed, they deserve to have as much information as possible about what lies ahead.

If those of us here in the United States don't have all the information ourselves -- and we (cue the chest-thumping) invented fracking -- how are our allies expected to figure it out?

*Correction, March 31, 2014: A quote that originally appeared in this article -- "Scientists simply don't know how to drill and frack a well" -- was incorrectly attributed as a direct quote by academics. The quote was a Columbus Dispatch reporter's paraphrasing of two academics' remarks. The quote has been deleted from this article. (Return to reading.) 

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