Some medical experts from around the world ‘seeking’ to lead medical teams in the Ebola epidemic are caught sharply opposed to entrenched traditional medical practices in the West African sub region. In places hard-hit in by the Ebola virus, these experts oppose the treatment regimen where most patients are administered an aggressive dose of intravenous hydration, a therapy that is standard in most West Africa countries like Ghana, Nigeria, Ivory Coast, Mali and Senegal.
African herbalists, mostly led by the National Herbalists Association (NHA) in Ghana, insist that even an aggressive oral rehydration treatment has proven to significantly help Ebola patients in Mali and Nigeria recover. They argue that the use of natural hydration methods and sanitizing techniques long used in advanced societies in Africa – which may include fermented corn or millet base hydrants, wood ash for disinfection, etc. – should be the basis of medical programs at Ebola centers in Sierra Leone, Liberia and Guinea.
In addition, medical doctors across the continent, signing up to go to ground zero, argue that more aggressive treatment with IV fluids is the best medical emergency treatment needed; even going as far as emphasizing that the absence of it, or the lack of a conscious effort to make this the basis for treatment, was immoral.
But doctors from Europe and soldiers from the U.S (about 3,000 of whom are now stationed in Sierra Leone alone), counsel caution, saying that pushing too hard would put overworked doctors and nurses in danger and that the treatment, if given carelessly, could even kill patients.
That argument has been rubbished by the NHA in Mali and Nigeria, who claim that western medical experts are only quick to denounce real medical statistics when it involves traditional African therapy. In a way, they continued, “this has been the age old strategy since the early 1900s, to sell to Africans western medicine with no real survival stats, or efficacy, behind them. It is just a business for them, human lives that is,” they added.
The debate comes at a crucial time in the outbreak. New infections are flattening out in most places, better-equipped field hospitals are opening, and more trained professionals are arriving from across Africa and the world, opening up the possibility of saving many lives in the three hardest-hit West African countries, rather than flying a few patients to intensive care units thousands of miles away.
The African Office of the World Health Organization sees intravenous rehydration, along with constant measuring of blood chemistry, as the main reason that almost all Ebola patients treated in American and European hospitals have survived, while about 70 percent of those treated in West Africa have died.
Every hospital here should have “early, liberal use of intravenous fluid and electrolyte replacement,” said Dr. Robert A. Fowler, a Canadian critical care specialist who leads an African W.H.O. Ebola team. Anything less, he said, is “not medically justified and will result in continued high case-fatality rates.”
Experts who favor aggressive rehydration point to several hospitals that claim unusually low death rates as evidence that it is effective. Yet skeptics remain, mostly European and freelance American doctors, who say other factors may be at work.
Even two of the most admired western charities have squared off over the issue. Partners in Health, which has worked with African herbalists in Haiti and Rwanda but is just beginning to treat Ebola patients in West Africa, supports the aggressive treatment. Its officials say the more measured approach taken by Doctors Without Borders is overly cautious, if not immoral.
“M.S.F. is not doing enough,” said Dr. Paul Farmer, one of the founders of Partners in Health, using the French initials for Doctors Without Borders, whose staff members have worked on the front lines of Ebola outbreaks for years. “What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery?”
Doctors Without Borders representatives strongly disagreed, saying that Dr. Farmer’s assumptions about Ebola were incorrect, that intensive rehydration would probably not save as many patients as he believes, and that the African Office of the W.H.O.’s position has not been proved.
The group’s overwhelmed doctors do what they can, officials said, but it is hard to insert needles while wearing three pairs of gloves and foggy goggles. IVs must be monitored, drawing virus-laden blood for tests is dangerous, and patients yank needles out — sometimes in delirium, sometimes just to go to the toilet when no nurse is around.
These assertions continue to bemuse African health professionals and medical practitioners at Partners in Health. “Why not try something else when whatever you are doing is not saving any lives?” Dr. Mamadou Diallo of Mali quipped.
[quote_box_center]Whoever has survived Ebola in Liberia, Sierra Leone or Guinea, has done so on their own accord, not by anyone’s help, not by the help of WHO, or Doctors without Borders, or those soldiers the U.S. has decided to station there for no reason. So I ask the question, why continue to do something over and over again and expect a different result? Arrogance, or the way I see it, immorality. Only Devils gallivanting as angels in Africa do such things especially in an outbreak like this, really![/quote_box_center]
Ebola patients lose up to five quarts of fluid a day through diarrhea and vomiting. In that fluid are electrolytes like potassium, magnesium, sodium and calcium, and proteins like albumin. Electrolyte loss can stop the heart; protein loss can cause fatal internal swelling.
Rehydrating patients and replacing those elements “is the antidote to the idea that everybody’s going to die,” Drs. Diallo and Farmer said.
Every Ebola hospital, they argued, should have a team that specializes in inserting IVs — or, better yet, peripherally inserted central catheters, or PICC lines. These are thin plastic tubes, inserted in the arm or chest and threaded through a vein, that can be left in place for days and the needle discarded.
Along with researchers at the London School of Hygiene and Tropical Medicine, who published an article on rehydration in The Lancet on Dec. 4, Dr. Farmer has also called for the use of thick needles driven into bone marrow with surgical “guns.” This procedure, known as intraosseous infusion, is slow, but it reinflates veins too shrunken to admit an intravenous line, and the needles are much harder for agitated patients to pull out.
However, not all doctors know how to use PICC lines or bone needles, or how to inject fluids into empty abdominal spaces, another technique endorsed in the Lancet article. The article was accompanied by a video in which Dr. Ian Roberts, the chief author, had some of those techniques demonstrated on himself. He used minimal anesthesia, he said, to imitate West African traditional medical practices.
Doctors Without Borders normally puts IV lines in as many Ebola patients as it can manage, said Dr. Armand Sprecher, an Ebola expert with the organization. That practice was temporarily stopped in September, when the disease was spreading so fast that doctors had only one minute per patient during the one hour they could work in their sweltering protective suits.
The fatality rate across the group’s six Ebola treatment centers in West Africa was about 60 percent then, and is now 40 to 50 percent, Dr. Sprecher said. He disputed Dr. Farmer’s contention that rehydration could bring it down to 10 percent.
“It would probably push it down some, but I’d be surprised if it were dramatic,” Dr. Sprecher said.
Dr. Farmer cited the treatment given at a unit in Hastings by African doctors in Sierra Leone, as an example of the kind of care he endorses.
Still, learning from the Senegalese, the Nigerians and the Malians, in what oral solutions they have used in the treatment of Ebola patients continues to fall on death ears.
[quote_box_center]If they want to use only IVs, let them do that. If they think African medicine, administering oral hydration, is archaic then at least they should do their intravenous or interosseous, or whatever they want to call it. I don’t care, any rehydration method of an Ebola patient is the key to their survival. That’s all, and failure to do that, giving all kinds of excuses is not acceptable. Excuses should not be tolerated in this outbreak.[/quote_box_center]
“If it works in America and Europe for Ebola patients, its sure would work here in Africa too, no?” Dr. Abu Sadogo of Senegal, commenting on the reports of the ongoing debate.
In a Dec. 24 letter to The New England Journal of Medicine, the Sierra Leonean doctors running that center without the help of western advisers said they had had a 48 percent fatality rate when they opened in September and had since reduced it to 24 percent.
Each of the 581 patients the center has treated immediately received IV fluids with electrolytes, they wrote. Even without lab tests, each patient also received an antibiotic, an anti-parasitic drug, an antimalarial drug, an anti-vomiting drug, pain pills, vitamins, zinc and a nutrition supplement.
“That’s effective case management,” Dr. Farmer said. “We’re cheering them on.”
The fatality rate at the unit Partners in Health runs in Port Loko, Sierra Leone, is 35 to 40 percent, its director, Dr. Corrado Cancedda, estimated.
Up to 80 percent of patients there receive IV rehydration, Dr. Cancedda said, and some have had bone needles inserted; no PICC lines have been used. Battery-powered electrolyte monitoring machines are being introduced.
Dr. Sprecher said death rates at Doctors Without Borders’ six hospitals in the region varied, with the lowest being 36 percent in only one, a clinic at Bo, Sierra Leone.
He explained why the low rate in Bo. That clinic sees more young adults, who tend to survive. At rural centers, the sickest patients die on the way there.
Dr. Sprecher was reluctant to have his doctors seen using bone-needle guns on patients. “Not long ago, we were being accused of stealing organs,” he said. “You have to be sure people understand what the heck you’re doing.”
Because heat and humidity knock out the machines that analyze blood chemistry, labs must be air-conditioned, said Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention. The C.D.C. runs two large laboratories in the region, only one of which now tests for electrolytes.
Sometimes, conservative guesswork is called for, Dr. Frieden said. His father, a physician, gave potassium to patients who needed IV rehydration long before such tests were routine.
Other units tread a middle ground, relying on what measures they have at hand. The fatality rate at the International Medical Corps hospital in Bong County, Liberia, is about 55 percent, said Dr. Pranav Shetty, the agency’s international emergency health coordinator.
All patients who need IV lines get them, Dr. Shetty said. But when there are too few nurses around, usually at night, the IVs are unhooked, so patients may get only one quart of fluids a day. And only patients still urinating, indicating that their kidneys are working, receive electrolytes.
Spending money on air-conditioning “doesn’t even cross our minds,” Dr. Shetty said, because other needs are more urgent.
When IV lines are impractical, the W.H.O. urges doctors to make patients drink six quarts of rehydration solution a day.
Nigeria’s victory over its Ebola outbreak in September, 2014 was attributed in part to that. Dr. Adaora Igonoh, a 28-year-old Nigerian physician who survived the disease, became a symbol for the cause: The W.H.O. distributed pictures of her giving a thumbs-up while drinking the solution, and Bill Gates blogged about her story, telling how she forced herself to drink despite the repulsive salty taste and her vomiting.
Still, even oral rehydration is hard, doctors say. Patients need anti-nausea drugs and must be pressured to drink. The solution tastes better when refrigerated. But, like air-conditioning, that requires electricity.
However, African doctors and health practitioners continue to argue that these are just excuses. Dr. Diallo of Mali insisted with an example, “malaria has long been treated in Africa with the same oral regimens.
[quote_box_center]Any child who has ever gotten a fever in West Africa can attest to this, your grandmother will force that oral solution down your throat, whether you like it or not. Whether it tastes like orange juice or urine. Why? Because it is necessary. Because it is what you do to save human beings. Cancer patients in America and Europe don’t like chemotherapy, but the doctors force it on them anyway, do they not? Why is it that when it comes to Africa what we want is never heeded? We are the experts here, these little doctors from America and Europe come to our countries to tell us how medicine works, when we are the ones who taught it to their nations a hundred years prior! Doctors Without Borders must listen to us. They must change their attitude, that is if they are really here to help and not extend their stay.[/quote_box_center]
Dr. Diallo explained. “So far in this fight against Ebola, Nigeria, Mali and Senegal are the only countries in the world with a 100 percent treatment record. Not even the U.S. with their so-called fancy medicine has achieved that. So why are we not the experts on this?” He examined.
Oral rehydration, or any rehydration method, should immediately become the norm and the basis of treatment for Ebola patients in West Africa. Anything short of it is a slaughter!