There is a stark and almost disturbing contrast between the hi-tech equipment used by these health workers and the rural African setting of those they have come to protect from the ravages of the rare but deadly Marburg virus.
Behind the masks, gloves and sweltering confines of the so-called astronaut suits are aid workers, doctors, virologists and epidemiologists. They have descended on the small town of Uige in Northern Angola to deal with the biggest outbreak of Marburg ever.
John Webb (Carte Blanche presenter): “Efforts by the Angolan government and aid organisations to isolate the Marburg virus means that getting in and out of Uige is extremely difficult. We’re going by chartered flight into the town that is at the very epicentre of the outbreak. It’s a trip that usually takes about 14 hours by road. Ironically, air transport is one of the ways this virus can be spread to other areas.”
Uige’s isolation may be the one thing that will stop the epidemic from spiralling out of control. Before Marburg came along, few people even knew that Uige existed. The provincial hospital had five doctors, serving 20 000 people, and it was in these wards that the epidemic took off in October last year, rampaging through the pediatric ward, infecting hospital staff until 17 health workers were dead.
The virus spread, carrying stigma and fear. Now the people of Uige don’t shake hands, the warm embraces are gone and a bowl of disinfectant is the welcome to many homes.
The Marburg virus first surfaced in 1967 when lab workers experimenting with African green monkeys for polio vaccines in Marburg, Germany, as well as Frankfurt and Belgrade, got sick. One died.
In 1975 it resurfaced in South Africa when an Australian traveller en route from Zimbabwe, became ill - ironically in a town called Marburg. He died.
In the eighties there were two cases in Kenya and then a major outbreak took hold of the mining town of Durba in the DRC, leaving 128 dead between 1998 and 2000.
Now it’s Angola’s turn. The death toll for the province stands at 136 as of today and there’s no end in sight.
International aid agencies have been pouring into Uige. The World Health Organisation has mobilised its Global Outbreak and Alert Response Network, or GOARN - an ad hoc team of international experts. The highly organised and dedicated team includes logisticians, anthropologists, virologists, pathologists and medical specialists to deal with the outbreak.
One of these is South African Microbiologist Professor Adriano Duse. He flew in last week to head an infection control team running the so-called ‘Safety Ward’ at the hospital.
Prof. Adriano Duse (Microbiologist, WHO Team): “There was a huge amount of suspicion amongst the department of immunity. There were rumours that in fact the hospital was at the source of the outbreak. Many people were also scared of coming out with the diagnosis, so, rather than report to the health care facility, would stay at home.”
John: “Malaria claims 40 000 lives a year in Angola but with the Marburg virus, death is so much more brutal. The early symptoms include a fever, rash, headaches and sore joints, then vomiting and diarrhoea set in until finally, as the virus moves through the system attacking the internal organs, patients suffer massive haemorrhaging and bleed from every orifice.”
Prof. Duse: “The general ethic of most doctors is to preserve life, and you can immediately tell - almost from a gut level - which patients are not Marburg and which patients are. And you also know at a gut level when you see those patients bleeding that the only treatment that you can give them is supportive, and we know that they frequently will come out [inaudible] dead.”
In the safety ward, patients with Marburg-like symptoms are screened and tested. Those who test positive or seem highly probable are destined for the Marburg isolation ward just across the courtyard.
Prof Duse: “If we make the decision - and really that’s where we have a huge responsibility - whether we are going to send them across to the isolation ward or not, we’ve got to be extremely cautious. I think that the isolation ward can be extremely traumatic and we have yet seen many patients that have expressed their concern and fear. We try and counterpart these patients by counselling patients and telling them that really this is a safe place, that really there are excellent infection control practices in the isolation ward and we’ll do our very best to ensure that they will go to a place where they will be looked after and treated comfortably.”
The ward is run by Medicines Sans Frontieres (MSF). Here confirmed and suspected Marburg cases are cared for under stringent safety measures. This part of the hospital is strictly off limits, but we were given exclusive access to film inside the ward.
First, we were taken through the preparation stages by Luis Encinas - medical co-ordinator for the MSF. The virus is transmitted through contact with infected body fluids like blood, urine, saliva and vomit. Health workers who come into direct contact with infected people and corpses need to take extreme precautions. These include three layers of gloves, goggles and no skin showing at all.
Our cameraman put on an astronaut suit and we wrapped a camera in plastic wrap to film exclusive footage inside the ward.
Family and friends are allowed to visit, and there is a place for people to observe the restricted zone.
In the confirmed Marburg ward there was only one patient, the rest of the ward was empty. There’s very little doctors can do for Marburg patients, besides re-hydrate, and try to treat pain and fever.
Nurse: “At the moment, the patient has arrived in a very late stage of infection and so, of course, the prognosis is a lot worse then.”
In the suspected ward there were two patients. Here they are monitored and blood is taken to test for the virus. Invasive procedures like intravenous drips are not used because of the danger of contamination by infected blood.
There is a recovery ward, but it’s empty. Only one patient in this unit has recovered, although doctors know of two others in the community.
Chlorine kills the virus and is used liberally in three different concentrations throughout the isolation ward. Most materials used or taken into the ward are incinerated.
Because the conditions are so harsh, the protective clothing so claustrophobic and the potential for mistakes so lethal, staff never work more than a two-hour shift in the ward, and rarely spend more than three weeks in Uige.
Luis Encinas (Medical co-ordinator, MSF): “We are here to isolate people and to break the outbreak of Marburg, so it’s very hard to really focus on the public health point and not the clinical patient because there is no treatment except for the symptomatic treatment.”
The majority of Marburg deaths do not come from the hospital or the isolation ward. Instead, they are picked up by the WHO (World Health Organisation) mobile contact teams that trawl the muddy slums for the sick, the dying and the dead. We went out with this team led by William Perea, an epidemiologist from Columbia.
Dr. William Perea (Epidemiologist, WHO Team): “The problem now is that they’re calling us for the bodies, we are going after the epidemic [has struck], we are not being effective.”
When they first entered Uige, the mobile teams and their hi-tech gear were met with fear, distrust, and anger. Earlier this month they had to suspend operations after being stoned and attacked in some areas.
Dr. Julienne Anoko (Anthropologist, WHO Team): “In the traditional system, every time you explain the problem, they are looking every time who is responsible - which sorcerer or witch is going to take the illness and bring it into the community.”
Dr Julienne Anoko is an anthropologist with the WHO social mobilisation teams that put considerable effort into combating the biggest factors fuelling the outbreak: superstition, ignorance and a deep distrust of western medicine.
Dr. Anoko: “We had some incidents within the community. Because they were not understanding that a person who died [have] to enter a sort of bag, they were afraid. A pregnant woman, she was seven months pregnant, and she began vomiting blood. And the husband closed the door as we recommended and the wife was crying, crying, crying. And when we arrived there it was too late, she was dead. And the hospital was full. He was crying; he told me, ‘I abandon my wife. I abandon my wife! [Why] do you think I am going to live now if I abandon my wife? She died alone’.”
John: “Every day the World Health Organisation’s mobile contact teams visit an area where someone is either sick or dead. There’s been a death in the house behind us and the team is currently negotiating for access to the body.”
The mobile teams have learned from experience - they only put on their suits after expressing their condolences, consulting the family and involving them in the process. After the team takes blood to test for the virus, the family is told how to deal with the body, and given protective clothing.
Dr. Anoko: “In the normal situation when there is a death, a funeral, what they do is expose the body somewhere or on the bed and they kiss him. They are dancing all around the body, kissing him, crying and singing. Now, with Marburg, we don’t recommend contact and there is a sort of shock.”
Marburg has changed things. Here, the team goes to a 20–year-old woman who died in a vehicle before her family could get her to hospital. After consulting her husband, the team decided to remove her body immediately. Before burial, the corpse must be “conditioned” or sprayed with chlorine, which kills the virus. Her husband assists the team and will be allowed to bury his wife, albeit without washing the body.
Dr. Anoko: “Here in Uige when there is a funeral, every assistant has to wash [their] hands in a bucket of water, and now we are using a disinfectant by putting bleach into the water, and we do…we control the situation and the ritual is going on.”
Dr. Perea: “Although this is a painful exercise for the family, the husband, for everybody, it is the only way that we are going to build that bridge and we hope that sooner than later they will understand that they can trust us and call us when people are sick. But we are not there yet, we are not there yet.”
There are some signs that the tide is turning in Uige, and that life will one day return to normal.
The Song Against Marburg, composed by local musician Amadeu Cardosa and performed here by the Marburg Trio, urges the people out of denial about the disease. It’s played on local radio and from loudspeakers around town.
Cardosa composed the song in memory of a musician friend who died of Marburg, along with almost his whole family
John: “How does it make you feel, to know that people you share this town with have lost their lives?”
Amadeu Cardosa (Local musician): “Whenever we lose someone, whether it’s a friend or not, we feel terribly sad. People are dying. We can’t just fold our arms, so we’re trying to do something to protect the remaining people.”
The epidemic is long from over and a number of questions remain unanswered, like where does Marburg come from and where does it hide?
Prof. Robert Swanepoel, from the National Institute for Communicable Diseases in Johannesburg, is an expert on haemorrhagic fevers. Since the first Ebola outbreak in 1995 he’s been trying to find the reservoir, or the carrier of the Marburg and Ebola viruses. It would have to be an organism that the virus doesn’t kill as it does humans and monkeys.
Prof Robert Swanepoel (Virologist, National Institute for Communicable Diseases): “We regard this as the Holy Grail… it’s like Mount Everest. It’s out there, but nobody’s climbed it. As long as it has not been climbed, we’re excited.”
After the 1988 outbreak in the DRC, Prof. Swanepoel went searching for the Marburg reservoir. The outbreak was traced to a mine that was full of bats and he found genetic evidence of the virus in bats. The research continues.
Prof. Swanepoel: “The people on the ground controlling the outbreak - WHO, NGOs like MSF, who are excellent at their job - but they all have priorities and you come in there and want to do something else, they say, ‘But hang on, now is not the time,’ and then you do wait and then later on, the trail has gone cold looking for the reservoir.”
John: “Professor, in non-scientific terms, how would you characterise the Marburg virus? Is it a silent assassin? Is it a biological terrorist?”
Prof. Swanepoel: “It’s we who create the situation and help it along. If it were by itself, if it were lying on the floor there, it can do nothing by itself. It holes up or lives in some other animal somewhere else - silently and peacefully - gets into humans, and people start bleeding and so on. Other people expose themselves through lack of knowledge…”
John: “And of course hospitals can very often be a problem?”
Prof. Swanepoel: “Hospitals can cause epidemics, but the problem is poverty really.”
John: “Has a vaccine been developed?”
Prof. Swanepoel: “There are people who are academically getting grants now and have worked on a vaccine and have had success. The game has become extremely expensive, no longer everyone in their own backyard making vaccines. It’s all become centralised in a few big hands in the world. And then you tell a company that sells millions of doses [of] measles to make [a Marburg vaccine]. What’s the demand of Ebola or Marburg vaccine? You make 10 000 doses, the outbreak goes away and nobody’s going to buy it.”
John: “What should South Africa be doing in this particular instance?”
Prof. Swanepoel: “We’ve done the right things, but we can’t swear it won’t happen here because there are thousands of South Africans working up there, there are people travelling to and fro from countries all over the world. The other day we had somebody sick on a plane who was just passing through South Africa.”
John: “This is how the majority of people in Uige live. There is no running water, no electricity and no sanitation. It’s conditions like these that make containing the Marburg virus such a logistical nightmare.”
For aid workers, it’s a daily struggle against trying conditions, both physical and psychological.
Dr. Gian Meyer (GP, WHO Team): “When you come home, you really feel like having a good shower, soap…and even, there is not enough water or not enough water for you to wash yourself properly and put on clean clothes.”
Prof. Duse: “This is not for the faint hearted. We often have to debrief ourselves in the evening. We have seen some terrible sights; you can see from our faces as the day progresses, it’s really extremely difficult and we’re finding it hard to cope.”
Although they take every conceivable precaution, health workers are in the front line when it comes to contracting Marburg.
Dr. Meyer: “The haemorrhagic fever in general is unknown territory. If I would die from Marburg, it would really be something I’d want to avoid because my children need me.”
Prof. Duse: “If the patient is not bleeding, we would like eye contact with our patients, we would like to talk to them, and not make them feel fearful. We find that we get better clinical information and other information if we do that, but we are also not heroes, and this is not a job for anybody who comes in here with a heroic attitude.”
Dr. Anoko: “For me, it is urgent for us to save the people that are alive, more than crying for those that died.”