By Jared Weber
In the thick of the 2014 Ebola virus outbreak in West Africa, the World Health Organization dispatched UNC-Chapel Hill physician Billy Fischer to provide medical care in Guinea.
Fischer had been in Geneva, Switzerland, to work on a different WHO project, when he received the call. Though he had been enthusiastic about his initial plan, he accepted the unexpected assignment with nervous anticipation.
His frame of mind completely shifted, though, during his arrival flight to Guinea.
In the air, Fischer began reading The Hot Zone, Richard Preston’s 1995 best-selling book about Ebola virus and other viral hemorrhagic fevers, on his e-reader. The book presents harrowing portrayals of the virus’s effects on humans, including vomiting attacks, abrupt losses of consciousness and heavy bleeding.
Naturally, Fischer arrived in Guinea expecting the worst.
“I was almost paralyzed by fear about what I thought I knew about Ebola,” Fischer said back home in North Carolina.
But once he entered his first Ebola treatment unit, his mood almost instantly shifted.
“That was the most comforting moment of that entire outbreak … when I walked in there for the very first time and saw the patients,” Fischer said. “I realized that everything that had been told to me about Ebola by mass media was completely wrong.”
The patients looked just like ones he had treated as a resident at Johns Hopkins, or in the intensive care unit back in Chapel Hill. Sure, the Ebola virus certainly exhibited some awful symptoms, but patients were still only in need of what those in Baltimore and at UNC Hospital receive: high-quality, compassionate care.
Due to the stigma surrounding the disease, however, that was not happening in Guinea. Health care workers had instead chosen to isolate Ebola patients.
While the WHO declared the initial Ebola outbreak over in November 2014, reports of new flare-ups have arisen in recent years; the Democratic Republic of the Congo announced two outbreaks this summer, with one still ongoing. Fischer and his colleague, fellow UNC-Chapel Hill physician David Wohl, have continued to visit West Africa multiple times a year.
In addition to treating patients, they’re also researching and testing a new Ebola drug, called Remdesivir, with the help of UNC epidemiologist Ralph Baric.
“What we are fighting for is for people to get the care they need. We’re doing it using clinical research and outbreak response,” Fischer said. “And, if we can do this for Ebola, we have to be able to do this for every other disease.”
Getting the basics down
In Fischer’s eyes, the foundation of care for the Ebola virus in Africa has been rooted in isolation. It’s a pattern that he said can also be seen in other highly stigmatized diseases, such as HIV and malaria.
Both Fischer and Wohl are aware of how difficult it is to change the culture of emergency health care in a continent that struggles to finance its own hospitals. According to the WHO Global Health Expenditure Database, of the 42 African countries that track their per capita health funds, 29 spend less than $50 per capita annually. To put that in context, the average wealthy country spends approximately $5,169 annually per capita, according to a report from Peterson-Kaiser’s health-system tracker. The United States drops a whopping $10,348 on average every year.
The DRC, where the two most recent Ebola outbreaks have occurred this summer, ranks last on the list — spending a mere $4 per person.
Still, Wohl thinks that much of the reason for the isolated care comes from a natural human response.
“Part of the problem is that it’s human nature, during an emergency, to concentrate on fixing that problem and getting rid of that problem,” Wohl said. “And then when the emergency is dealt with, we relax our guard and no longer pay attention to the problem.”
It’s the time in-between outbreaks when Wohl says progress can be made.
He likened emergency medical response in Africa to firefighting. Firefighters do not improvise on how to put out flames once an incident has occurred, he said. They practice and prepare for situations before anything happens.
“It’s a lot of practice and preparation,” Wohl said. “We don’t do this so well when it comes to outbreaks of infectious diseases, and I think it shows.”
Instead of “recreating the wheel” every time, as he put it, Wohl says it’s necessary, in the aftermath of an outbreak, to analyze the performance, and then prepare for the future accordingly.
He picked apart the overall response to a recent outbreak of Ebola in the Equateur Province of the DRC.
The outbreak, which officially ended July 24, resulted in 33 deaths from 54 total cases, according to a report from the WHO.
He said that therapeutic drugs didn’t arrive fast enough, resulting in some patients not receiving appropriate medication. Wohl also added that there was no coordination with the local ministry of health before the outbreak, which he said would have allowed integration of therapies and epidemiological research.
It’s far from his ideal situation, in which impoverished countries strengthen their health systems so they can coordinate their own national response.
“We need to see the capacity built up so there can be a national response that’s effective and well-coordinated with international partners,” Wohl said.
Wohl said the world’s wealthiest countries should finance this infrastructure in impoverished countries, as well as rudimentary health care in general.
“Foundational health care is one of those basic fundamental rights,” Wohl argued. “We spend billions of dollars on all sorts of things that, if funneled to these types of efforts, could make a huge difference, and maybe even solve the problem.”
Stopping replication
As Fischer and Wohl have cared for patients in West Africa, they’ve also been running clinical trials for Remdesivir, a new antiviral drug, to see if it could potentially treat Ebola virus.
Gilead Sciences, Inc., in coordination with the Centers for Disease Control and Prevention, had originally been developing the drug’s molecules as a possible treatment for human respiratory syncytial virus, or RSV, a common virus that can cause dangerous respiratory infections in weak or compromised immune systems. The company had also hoped for the particles to treat hepatitis C.
As 2014 unfolded, though, Gilead decided to explore the molecules’ potential to treat Ebola virus. After viewing cell cultures, they found Remdesivir might be able to stop the virus from replicating.
“So then, they put it into non-human primates and they found that they could survive if they were treated with this drug,” Fischer said.
For Fischer and Wohl, the most attractive facet of this drug is its potential to stop replication in all strains of the Ebola virus. ZMapp, one of the cocktail antivirals most commonly used to treat Ebola, only stops replication in the Zaire strain of the virus.
[sponsor]If Remdesivir does prove to be an effective pan-Ebola drug, Wohl said it would completely change the way outbreaks are approached.
“That would mean that, any time there’s a flash of an outbreak, the trick would be making sure that there’s access to [Remdesivir] quickly,” Wohl said. “One can imagine, easily, that the drug would be stored in places where outbreaks happen — like in the DRC, maybe in West Africa. That way, people who get infected can get access to this early and break the chain.”
Fischer and Wohl have teamed up with the National Institutes of Health to lead clinical trials of Remdesivir in Liberia and Guinea. Currently, they’re testing the semen of male Ebola survivors to see if replication really does come to a halt.
So far, Remdesivir has been used to treat two patients with the Zaire Ebola virus strain. While both of the patients survived — one of whom was the first infant to ever survive the Zaire strain — they had also been receiving ZMapp.
“The next step is to trial these two drugs, either together or against each other, to try to figure out if one is better than the other, or if the combination is better than either alone,” Fischer said.
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