Ebola Hemorrhagic Fever

Introduction

The nearly simultaneous outbreak of major epidemics of Ebola hemorrhagic fever in Sudan and Zaire during late 1976 served as a poignant reminder that infectious diseases have not been eliminated.  Ebola hemorrhagic fever is a severe, often fatal disease in humans and nonhuman primates, which was first isolated in Zaire in 1976.  Ever since its discovery, single cases and large epidemics have recurred with over 1850 recorded cases and 1300 reported deaths.  Symptoms include, but are not limited to, arthritis, diarrhea, nausea, vomiting, headache, gastrointestinal bleeding, conjunctivitis, depression, and hemorrhaging.  With an extremely high fatality rate between 50-90%, it is logical to assume that there would have been a widespread panic during each outbreak, mimicking responses of other virgin soil epidemics; surprisingly, however, this has not been the case. Past perceptions of Ebola hemorrhagic fever have ranged from the expected fearful, panic, to a calm, indifference. Depending on both the year and region, past perceptions of Ebola have differed immensely. Parts of the world that were not exposed to Ebola in the 1970s drastically changed their perception of Ebola by the 1990s while those chronically hit by the virus had an amplified panicked reaction to subsequent disease outbreaks. When focusing on both the United States and the region of Central Africa (specifically Zaire and Sudan) during the early years of the first outbreak (1976-1978) and later on during the 1990s, it is important to realize that past perceptions varied, yet, there has always been a threat of “bioterrorism” in regards to Ebola. Bioterrorism is defined as the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants.  The threat of Ebola as a potential agent for bioterrorists has stigmatized the virus and has exacerbated people’s reactions toward the disease. 

Early Perceptions of Ebola: The Medical Community

The first primary source that I looked at was titled Ebola haemorrhagic fever in Sudan, 1976, which is a World Health Organization (WHO) report on the first large outbreak of Ebola that occurred between June and November 1976 in Sudan. In this outbreak, Ebola hemorrhagic fever had a high mortality rate (ranging from 50-60%)  with a total of 284 cases.   The most surprising thing about this outbreak was how closely this epidemic resembled virgin soil epidemics that we had talked about in class, in the sense of the sheer destruction that it caused in terms of mortality. What was also really interesting was that the disease was amplified by transmission in large hospitals—close contact/nursing patients led to even more disease. From the observations made by the WHO, it was evident that nursing a patient was almost a requirement for becoming infected (39 of 48 instances); therefore, a hospital was the ideal environment in which disease transmission occurred.   Continuous contact with patients by staff at a hospital in Sudan that operated a large nursing school accounted for the bulk of cases occurring in the country . 

Unlike Polio or the Black Death, there is little to no reporting on people’s perceptions of the disease during the 1970s. In fact, after searching through ProQuest Historical Newspapers, PubMed, and JStor, I only found one relevant article that described the feelings and experiences of the survivors of the Ebola epidemic; however, this was from a 1995 epidemic. All of the accounts of Ebola from 1976 are focused on an epidemiological perspective and not a social one; thus, this source was particularly interesting because it allowed for comparisons with previously studied diseases. The WHO article was significant because it really opened the door for a lot of questions and further explanations about the social effects of Ebola. Since Ebola is not only highly contagious, but also possesses a high mortality rate, how would society have reacted to the disease? Would there have been panic? Would people have abandoned each other, like what happened during the Black Death? Unfortunately, with the limited resources provided online, these answers were unable to be concretely answered. However, by considering the horrific physiological effects of Ebola with its contagiousness and high mortality rate, it is possible to make an educated guess that there would have been a widespread fear and panic, especially when hospital staff was being hospitalized for the disease after taking care of patients. Through further research I found one other source that mentioned that the 1976 outbreaks caused considerable disruption to the economy of the affected areas, but again, this was the only social impact mentioned, there was nothing to be said about African perspectives of the disease.  

The second primary source that I looked at was titled Ebola haemorrhagic fever in Zaire, 1976, which was also a WHO report on the subsequent outbreak of Ebola in Zaire. Before the outbreak, the disease was still unknown to the people of the affected region—news of the Sudanese outbreak had not yet reached Zaire.  Surprisingly, this outbreak was larger than the one that was occurring simultaneously in Sudan. Unlike the 284 reported cases in Sudan, there were 318 reported cases of viral hemorrhagic fever occurring in northern Zaire, with 280 deaths, and only 38 serologically confirmed survivors—a death rate of approximately 90%.   The death rate was extremely shocking because it was unprecedented in comparison to any of the other diseases studied in class, with only rabies having a higher reported death rate.  As the epidemiology of the disease was still unknown, use of protective clothing and respirators, strict isolation of patients, and careful disposal of potentially contaminated excreta and fomites was employed . What was most interesting about this source was that it hypothesized how the two outbreaks in Zaire and Sudan were linked: sharing needles. It is believed that contaminated needles and syringes were responsible for much of the morbidity in Zaire with  no person who was infected in such a manner surviving.  This was especially interesting to me because Zaire was the epicenter for AIDS around the same time period and both are thought to have occurred due to contact from primates—with bodily fluids, especially blood, as a mode of infection. The main reason why I found this interesting was that , while the AIDS epidemic has many sources chronicling the social effects of the disease, Ebola has none. This disparity is not easily explained, and would probably require much further research. At the present I can only hypothesize that AIDS garnered more attention due to the fact that AIDS was able to spread worldwide, while Ebola has remained relatively isolated in central parts of Africa. 

These two sources are both past perspectives of the medical community, especially the World Health Organization and linked governments. These articles do not focus on the social implications of the disease, only on the epidemiology, thus giving insight that during 1976, the most important goal of the medical community was to isolate the virus and figure out what it was and how it could be combatted.  Ultimately, however, these sources both described the failure in obtaining the critical information necessary to prevent outbreak, citing delays in recognition, delays in notification to international health agencies, and the inability to specifically diagnose the disease as contributing to this issue.  In fact, these articles seemed to use Ebola as a scapegoat to perpetuate a specific agenda that revolved around emergency outbreaks. Basically, these articles called for a national disease surveillance and the prompt solicitation of international assistance and for the development of international resources (personnel, equipment, transport, communication, and finance) that can be made available in a very few days to cope with emergencies. 

Early Perceptions of Ebola: Newspapers

Unlike the various medical sources that discussed Ebola from an epidemiological perspective, newspapers, especially American ones, did not even substantially report on Ebola until the 1990s. In fact, when searching for Ebola related news articles from 1976-1978, there were only two newspaper articles that actually talked about the Ebola epidemic that was going on in Zaire and Sudan. The first article that I referenced was titled “HEALTH TEAM FIGHTS DEADLY AFRICAN VIRUS: Medical Personnel Risk Infection in Hunt for Blood Plasma From Survivors of New Disease,” which was published by The New York Times in 1977. This article emphasized the 600 people who died because of the “deadly new viral disease,” and predominately focused on treatment.  As with the medical sources, this newspaper failed to mention any of the social problems that occurred in Zaire and Sudan. The second article that I looked at was published by Los Angeles times in 1978 titled “2 Years Later, Virus Source Still Sought: Immunizing Plasma Ready If African Disease Reappears VIRUS STUDY.” This article mimicked the earlier article published in the New York Times by emphasizing the 600 people killed due to a “mysterious virus.” This article focused more on research and what scientists are doing in the lab to combat Ebola if the disease reappears.  Again, however, there is no mention of the people who were affected by Ebola and how they reacted to the epidemic. Both of these articles were brief, perhaps only a column or two when actually printed on a newspaper page—they were not large articles that went in depth about the Ebola epidemics. 

Due to the severe, and in my opinion, shocking lack of substantial reporting, these articles indirectly showed that the United States general public did not care about what was going on with the Ebola outbreak. The American perspective of 1976-1978 was one of a cold indifference based on the fact that the majority of major news sources did not report about Ebola at all. Furthermore, those major news sources that did report on Ebola dedicated barely half of a page, and even then, there was only one article per year published in two separate newspapers. These articles also show that nobody really knew the cause of the outbreak, especially in the scientific community. There was only speculation at this point about what had happened and how the disease had ever spread. In the years directly following the first Ebola epidemics, everything was very hypothetical. There were a lot of “what if” questions that were being asked in these news articles that reflected the scientific inquiry into the disease, in fact, they were even questioning whether or not rodents had contributed to the spread of the disease.  Basically, there was nothing concrete to be said about Ebola from a “cure” standpoint, as well as one of a social issue standpoint. 

Besides American newspapers, there was not a lot of coverage in the European press either, based on the searches that were done using the  ProQuest Historical Newspapers database. The only non-American source that covered Ebola was the Jerusalem Post, an Israeli based newspaper, in a 1978 article titled Soviets said breeding ‘super-lethal’ viruses. This article linked Ebola to Soviet bioterrorism.   I found this extremely interesting because I had never really known that there was a “paranoia” with bioterrorism pre-1990s. I had never even considered that as far back as the 1970s, Ebola was seen as a potential weapon of mass destruction. What was even more surprising was that it was an Israeli newspaper that was speculating about a Soviet bioterrorist threat. I would have thought that the United States would have published articles linking the Soviets with bioterrorism due to the fact that the Cold War was going on at the time and there was a large anti-Soviet sentiment in the United States. It was just very shocking to me that Israeli newspapers would have linked the two when American media outlets did not. That being said, the main reason why I chose this source was because it sheds an insight into non-American perceptions of the Ebola outbreak.  It also is a good segue into the 1990s perception of Ebola. The “bioterrorist” threat mentioned in this article is mimicked in a lot of post-1990 articles as well. This article shows that while predominant 1976-1978 perceptions focused on the epidemiology of Ebola, this soon transitioned into focusing on Ebola and its capabilities as a bioweapon. 

Perception of Ebola in the 1990s: Bioterrorism

The main source I looked at was a newspaper article in the Washington Post titled Media’s Portrayal of Ebola Virus Sparks Outbreak of Wild Scenarios. By the 1990s the western world had a much different attitude towards Ebola.  In 1989 Ebola-Reston virus was introduced into quarantine facilities in Virginia and Pennsylvania by monkeys imported from the Philippines. This occurred once more in 1990 in quarantine facilities in Virginia and Texas. In the 1990 incident, four humans developed antibodies but did not get sick.  What was most interesting was that there was evidence that transmission could have occurred through air.  The high fatality rate combined with airborne transmission fueled media and general interest in Ebola and a lot of books/movies have come out that focus on the virus.   When Ebola broke out again in 1995 there was a huge media/tabloid campaign, which fueled public fear.  The media and medical journals no longer solely focused on the epidemiology of the disease; there were articles written about the 1995 epidemic that emphasized the survivors and their feelings and experiences. There were initial feelings of fear, denial, and shame. Survivors were abandoned by their friends and family, and hospital staff was reluctant to treat them.  These social effects mimic past perceptions of diseases such as Leprosy and AIDS. The disease was perceived as shameful, and there was a lot of fear s surrounding the disease—something that probably occurred in 1976 as well. 

The link between Ebola and the media as a cause for Western panic surrounding the disease was previously unknown to me. The various mediums about Ebola sparked panic and caused a lot of wild scenarios to appear, and the threat of bioterrorism was a common theme.  It was just really interesting to see how attitudes changed once it became more “relevant” to the United States. Ebola went from being relatively ignored, so becoming a sensationalist news headline. Ebola is not as widespread in numbers as other epidemics, yet, there was a huge media campaign surrounding the virus. This got me wondering how does media coverage perpetuate the amount of care the general public has for a disease? How real is the bioterrorist threat? In an attempt to answer these questions, I turned to secondary sources that focused on bioterrorism—most revolved around anthrax. While none of the secondary sources focused on Ebola, one that was read in class highlighted the reminder of the sophistication and advances in microbiology.  This source states that it is likely more attacks of bioterrorism involving other pathogens may occur—causing a new challenge for the health care community.  This source not only leaves open the possibility of an Ebola bioweapon, but also states that bioterrorism is a real threat that may happen once more. 

Conclusion

Past perceptions of Ebola hemorrhagic fever have differed throughout the years, mimicking patterns of other previously studied diseases. As Ebola became more relevant to the United States, fear and panic was perpetuated by the media; panicked reactions that also occurred in Africa to those directly affected. The threat of Ebola as a potential agent for bioterrorists has stigmatized the virus and has exacerbated people’s reactions toward the disease, keeping Ebola on the forefront of bioterrorism. 

Bibliography

“2 Years Later, Virus Source Still Sought: Immunizing Plasma Ready If African Disease Reappears VIRUS STUDY,” Los Angeles Times, Aug 20, 1978: 2.

Altman, Lawrence K., “HEALTH TEAM FIGHTS DEADLY AFRICAN VIRUS: Medical Personnel Risk Infection in Hunt for Blood Plasma From Survivors of New Disease,” New York Times, Jan 25 1977: 12.

Borchert, M. et al.,“Viewpoint: Filovirus haemorrhagic fever outbreaks: much ado about nothing?” Tropical Medicine & International Health 5 (2000): 319.

De Roo, Ann et al., “Survey among survivors of the 1995 Ebola epidemic in Kikwit, Democratic Republic of Congo: their feelings and experiences,” Tropical Medicine and International Health 3 (1998): 883.

Draper, C.C,  “Haemorrhagic Fever in Africa Due to Marburg-Ebola Viruses,” Disasters 1 (1977): 313.

 “Ebola Hemorrhagic Fever,” The New York Times Health Guide, http://health.nytimes.com/health/guides/disease/ebola-hemorrhagic-fever/overview.html

 “Ebola Virus,” Baylor College of Medicine Department of Molecular Virology and Microbiology, http://www.bcm.edu/molvir/ebola

 “Emergency Preparedness and Response: Bioterrorism Overview,” Centers for Disease Control and Prevention, http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebola/qa.htm

Emond, R. T. D. et al, “A case of Ebola virus infection,” British Medical Journal 2 (1977): 541-544

Johnson, Karl M. “Ebola Virus and Hemorrhagic Fever: Andromeda Strain or Localized Pathogen?” Annals of Internal Medicine 91 (1979):117-119.

 “Known Cases and Outbreaks of Ebola Hemorrhagic Fever, in Chronological Order,” CDC Special Pathogens Branch, http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebola/ebolatable.htm

Lane, Clifford and Anthony Fauci, “Bioterrorism on the Home Front: A New Challenge for American Medicine,” Bioterrorism. Guidelines for Public Health Management, Chicago: AMA Press (2002), 7-10.

Report of an International Commission, “Ebola haemorrhagic fever in Zaire, 1976,” Bulletin of the World Health Organization 56 (1978): 271-93.

Schwartz, John, “Media’s Portrayal of Ebola Virus Sparks Outbreak of Wild Scenarios,” The Washington Post, May 14 1995: A3.

“Soviets said breeding ‘super-lethal’ viruses,” The Jerusalem Post, Jan 31, 1978: 1.

WHO/International Study Team, “Ebola haemorrhagic fever in Sudan, 1976,” Bulletin of the World Health Organization 56 (1978): 247.