Ruminations of an Ebola Fighter: An Interview with Tim Jagatic, MD

Editor's Note: MD Magazine contributor Sanjey Gupta, MD is an expert in wilderness medicine. While lecturing this summer in in Breckenridge, CO he interviewed Tim Jagatic, MD. Both were attending the Wilderness Medical Society Annual Assembly. .

Much went wrong in the global response to Ebola. But some things went well and lessons were learned. Despite the initial deluge of news regarding the progress of the Ebola virus disease (EVD) epidemic, there is little valuable reporting in the public sphere regarding the current status of the fight against this disease.

As I sit with Tim Jagatic, MD, a Canadian physician who is a veteran of three volunteer missions with Médecins Sans Frontières (MSF) to West African EVD treatment centers during the uptick, height, and taper phase of the epidemic, I sense a sentiment of dissatisfaction with the global reaction to the epidemic.

In a word, he feels that the initial global response to the EVD epidemic was a “failure.”

According to statistics offered by the World Health Organization (WHO), as of the week ending December 30, 2015, the epidemic had claimed 28, 601 suspected or confirmed cases and resulted in 11,300 deaths worldwide. Jagatic first treated patients with EVD in April, 2014 in Guinea.

He recounts that at that time that a treatment center was literally being built around him as he was first treating infected patients. Limited medical infrastructure for patient care had been created at that point of the epidemic. He reports that MSF (also known as Doctors without Borders) was well suited to help manage the outbreak as the organization had roughly 40 members with prior experience with treating EVD. However, according to Jagatic, the location of the outbreak posed the larger challenge.

This was the first EVD outbreak in an urban setting with its accompanying high population density and poor physical and logistical infrastructure. The behavioral patterns and cultural norms of the local population regarding illness facilitated this EVD outbreak to progress to epidemic status. Further, Jagatic said that cooperation between many of the non-governmental organizations (NGOs) in West Africa at that time did a poor job of data sharing and collaboration, which contributed to the failure in recognizing the extent of the disease. That lapse also secondarily assisted in the propagation of the disease.

Jagatic does not mince words. He says that by June, 2014, that “Ebola was out of control.” He recalls that the number of ill seemed to be increasing exponentially and that the number of EVD treatment centers could not be increased without an increase in security. Relationships with the local population were souring as distrust of MSF and the other NGOs was increasing due to poor communication and due to the scope and description of the disease.

The local population had never previously encountered Ebola, and often confused the disease with more benign illnesses like malaria or typhoid. The local population harbored much distrust of NGOs, seeing them as infiltrating their communities and wreaking havoc on their social norms in dealing with their sick or dying. He says that the participation of the rest of the world in the fight against EVD was poor and no one seemed to respond to the pleas for help. It occurred to Jagatic that MSF seemed to be the only organization providing meaningful medical response as it was the only group with experience treating EVD.

In July, 2014, Jagatic was stationed in Sierra Leone and reported treating up to 20 patients with EVD per day. During that time, MSF ramped up its operation in Brussels, providing a training facility for an increasing number volunteers for skills in PPE placement, in the approach to and handling of patients with EVD, with increasing emphasis on reducing personal exposure. Jagatic continued to feel that national governments were ignoring the outbreak. The turning point seemed to come when Kent Brantly, MD, working with the organization Samaritan’s Purse, contracted EVD and became the first American to return to the United States to be treated for the infection.

After the media exposure of Brantly’s infection and treatment on US soil, the United Nations declared EVD a public health emergency of international concern. After that declaration, Jagatic noticed an increased international response.

The number of patients and intensity of disease was high in July and August, 2014. At that point, the intake of new patients in EVD treatment centers topped out after 30 minutes as the only available beds were the beds left open from deaths the night before. Many patients with suspected infections were forced to be treated in the community as the resources in the EVD treatment centers were outstripped by disease incidence. These patients and families were given gloves, chlorine bleach, buckets, and explicit instructions on how to avoid contamination, and were monitored at home.

During this peak time of the EVD epidemic In West Africa,. Jagatic describes the work environment as chaotic. Jagatic makes it very clear that the media-driven fear and sensationalism surrounding EVD made the work much harder.

Per Jagatic, the “media hysteria drowned out the science.” He feels that the media sensationalism contributed greatly to EVD being a destabilizing disease. He cites examples of media-driven hysteria driving public policy decisions. Those include mandatory quarantines on travelers who had contact with EVD disease--enacted in New York and New Jersey on the recommendations of the US Centers for Disease Control and Prevention -- and the decision of many academic universities to prohibit their physicians and public health experts from working in West Africa. These decisions may have decreased the pool of expert workers who could have helped squelch the disease at its source. Jagatic felt that the media was driven by a need to get viewers and readers. That “sparked and fueled inaccurate notions without accessing proper scientific literature.”

Coupled with the hysteria was the continued discordance between epidemic control strategies offered by organizations like MSF and the WHO and the behavioral patterns of the local populations. That discord also contributed to the spread of the disease.

Despite aggressive approaches to disease identification and monitoring, including potentially dangerous field investigation, identification, monitoring, and tracking of possible cases, EVD workers had to navigate a local community with a collapsed health care system, EVD-related rioting, severe stigma surrounding those who survived the disease, and a misunderstanding of the incubation period of the disease and transmission by body fluid contact of infected people.

When Jagatic returned to West Africa in December, 2014, he noticed a considerable change in disease management and in the participation of the local communities in gaining control over disease spread. There was a massive decline in the rate of spread of the disease, to the point that treatment center began to close for lack of patients to see.

The defining factor in slowing disease spread was behavioral change within the local communities. They had alligned their practices with recommendations that had been put forth by MSF and other similar organizations. Disease-containment strategies also shifted from treatment and disease surveillance beginning at the treatment centers to staffers and health professionals investigating and following potential cases in the community. With the increased number of experienced health workers providing more intensive treatment with increasingly complex approaches to patient care, the mortality rate of EVD dropped, the stigma surrounding the disease decreased, and positive community based behavioral changes were able to be maintained.

It has been little over a year since the overblown media coverage and political response to the case of Craig Spencer, MD, the New York City physician who contracted the virus while serving those who were ill in Guinea. He was there with MSF. Coincidentally, it was Jagatic who persuaded Spencer to volunteer there.

With the World Health Organization declaring that Guinea was free of EVD transmission for the first time since March, 2014 just this past week, the work of EVD fighters has finally been actualized.

Jagatic is optimistic.He says an experienced talent pool of EVD workers has been created, practice-validated treatment plans have been developed, and greater understanding of disease virulence and transmission patterns exists. He does hope that the lessons learned during this epidemic are positively utilized during the world’s approach to the next multi-national epidemic.