An Outbreak of Outbreaks: Humanitarian Epidemiology in West Africa

by John Pringle

I was disappointed that I couldn’t go to West Africa sooner. The Ebola epidemic was at its peak in the fall of 2014, the same time that I was preparing for my doctoral defence. I watched “Ebola Frontline” which conveyed tragedy and urgency. The documentary followed Médecins Sans Frontières (MSF) doctor Javid Abdelmoneim as he cared for Ebola patients in Sierra Leone.[1] It was graphic and raw, something out of Dafoe’s A Journal of the Plague Year. That people had to be turned away from Ebola treatment centres was profoundly inhumane. That traumatized aid workers had to turn people away because treatment centres were overrun, to watch helplessly as people died agonizing deaths in cars or on the ground—was yet another searing reminder of our collective failure, that there is no shared responsibility for global health, and that our notion of ‘international community’ is more dream than reality.

As an epidemiologist with MSF, I had experience responding to other outbreaks in West Africa. In 2006, I was a project coordinator for a team that travelled across northern Nigeria at the height of meningitis season. We conducted active case finding, organized targeted vaccination campaigns, and provided medical care to children with the devastating illness. The project was exhausting. There was virtually no functioning public health system so we improvised according to need. Our challenges were compounded by the remoteness of affected villages, the grinding poverty, and the delicate political tightrope we constantly had to navigate. And although I struggled with the long working hours and oppressive heat, I was safely vaccinated. I had the privilege of a $400 meningitis vaccine (meningococcal A/C/Y/W135) back in Canada, a luxury not afforded to the millions of people living with the African meningitis belt. That year, like the many before and after, meningitis killed young children and left many survivors blind, deaf or disabled.

Four years later I was back in northern Nigeria helping to respond to what is considered the worst lead-poisoning outbreak in modern human history. After the 2008 global financial crisis, investors around the world withdrew from stock markets and invested in gold. The price of gold spiked, drawing poor subsistence farmers into artisanal gold mining—the process of grinding down stone ore to extract flecks of gold. Sadly, the miners were not aware that the stone contained naturally occurring lead. Artisanal mining dispersed a blanket of lead-contaminated dust over villages, resulting in the deaths of hundreds of children and the chronic lead poisoning of thousands of others. As with so many outbreaks in neglected communities, the response was a humanitarian one. As a first for MSF, we set up life-saving chelation therapy in field hospitals and coordinated remediation of contaminated homes. Throughout it all, the World Health Organization (WHO) was too much on the side-lines. Once investigators learned that it was lead poisoning rather than a novel infectious disease capable of spreading, the ‘international community’ lost incentive to save lives and alleviate suffering—relegating it to private charities once again.

These experiences were on my mind as I departed for Sierra Leone on December 30, 2014. I spent New Year’s Eve in transit, sharing a bottle of champaign with fellow aid workers at a Casablanca stopover. In the early hours of New Year’s Day, I joined the MSF team in Freetown where I spent the next seven weeks as a field epidemiologist. I helped support two key MSF programs: the mass drug administrations of antimalarial medications;[2] and our newly opened Ebola management centre.[3] No two days were the same, and while I worked hard, everyone worked as hard or harder. I felt admiration and awe for my co-workers’ daily commitment: a constant reminder of the seriousness of the context and the importance of our projects.

Our Ebola management centre accepted its first patient on January 8, and in addition to regular Ebola cases (if there is such a thing) the centre specialized in maternity Ebola cases. Ebola is devastating, but it has particular ferocity in pregnant women. Very few pregnant women survive Ebola, and no baby born to an infected mother has survived. The Ebola virus crosses the placental barrier and concentrates in the placenta, fetus, and amniotic fluid. Pregnant women with Ebola almost always have a miscarriage or preterm delivery with haemorrhage and shock. Attending to undiagnosed Ebola obstetrical emergencies is particularly biohazardous and has infected multiple caregivers. Tragically, many of Sierra Leone´s precious few qualified healthcare workers died from Ebola, and many were infected while tending to women in labour.

Needless to say, for our Ebola management centre, ensuring biosafety protocols for the Ebola maternity ward was a high-stakes challenge. An important consideration: in the rare case when a pregnant woman survives Ebola (i.e., she is sero-negative and is left with Ebola antibodies), her Ebola antibodies do not cross the placental barrier. Therefore, the placenta, fetus and amniotic fluid retain a high viral load, and the fetus almost always dies in utero. Even though the pregnant woman’s blood test for Ebola is negative, the delivery remains highly infectious. Therefore (and here it gets complicated), a pregnant woman who survives Ebola and who tests sero-negative could return to her village, go into labour, and inadvertently infect those attending to her delivery. Because of this risk, pregnant Ebola survivors must remain in Ebola management centres until their very carefully planned and induced delivery. Sadly but not unexpectedly, the few fetuses that have survived to delivery have died shortly after. During delivery, maternal antibodies protect the woman from the Ebola virus exposure, so that following the delivery she remains sero-negative and is able to return home Ebola-free.

My narrow experience of the three outbreaks—meningitis, lead poisoning and Ebola—demonstrates how poverty kills. Outbreaks flourish where there is insufficient investment in essential public health services, where poverty is the norm, where global neoliberalism sacrifices community health on the altar of free market capitalism. The absence of the profit motive in addressing the community health needs of the poor results in a ‘global coalition of inaction’. To think anything else is not just naïve, but dangerous amnesia. So here we are again, hearing the echoes and tired mantras familiar to seasoned, disillusioned aid workers: ‘unprecedented’; ‘valuable lessons’ and ‘never again’.

John Pringle ( is a nurse and epidemiologist with a PhD in public health and bioethics from the University of Toronto. He is currently a Postdoctoral Fellow in humanitarian health ethics at McGill University. His work takes a critical approach to bioethical issues surrounding humanitarian action under globalization and global health governance. In addition to his work in Canada, he is a member of Médecins Sans Frontières (MSF) and has worked in Eritrea, northern Nigeria, and most recently in Sierra Leone during the Ebola crisis.

[1] Produced by Blakeway Productions for the BBC in association with CBC News Network; producer and director Steven Grandison.



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