Fieldset
Chapter Four: Mbandaka, Week 2, +27 degrees, clear sky

Luis, an Ebola specialist, blogs about the trail of a potential new vaccine, which could protect health care staff during the current outbreak in the Democratic Republic of the Congo...

I'm writing from the end of the world, or thereabouts. That’s how I want to start my journal entry today. 

Day 6, and yet I feel like I’ve been here for two months - the days are so long, busy and heavy. 

I look through the plane window. Flying over the equatorial jungle takes your breath away. The density of the forest and the blinding green is so beautiful that only the most sensational documentaries can attempt to reproduce it. 

During this period, the epidemic, like the first stage of an avalanche, advances discreetly.  

Why am I back in Congo? For many years a strange kind of relationship has connected me with this country. It’s been a love-hate, smile-and-despair relationship, but also a range of feelings and frustrations that dance in my head and in my guts. 

Ebola has struck again in its original locations, where it was discovered just over 40 years ago. Not an epidemic like those we have often seen in this country during the last decade, but an epidemic that has arrived, wrapped in local enchantments, with surprising strength this time around. 

Between 2014-2016 there was an Ebola epidemic in West Africa. And now we can think of things as 'before' and 'after'  that outbreak. 

Evolution of an epidemic

While we do not know the exact evolution of this epidemic, I cannot help falling easily into this trap – tracing it in my mind: an underlying epidemic discovered recently by chance, growing in strength in many clusters, the chains of transmission, the transformation of a rural epidemic to an urban epidemic ...  

This last point causes me sleepless nights.  

When someone is diagnosed with Ebola, it's vital to follow-up with people they have been in contact with and may have infected. For this epidemic, this follow-up is still in a very preliminary state. During this early period, the epidemic, like the first stage of an avalanche, advances discreetly.  

Alas, Ebola is the disease of "people who care"...

The other reality that gives me chills concerns the risk represented by front-line health care staff in the face of the disease.

Looking for the positives 

But this morning, I decide to see the positive side. Things have changed since 2014, especially when it comes to an epidemic like this. 

First of all, humanitarian organisations have been activated quickly, without delay. Still, the response must be coordinated, clarified, shared and followed. That's another chapter probably.  

Then, and this is what I wanted to get to, the provision of the new vaccine, still in its clinical trial stage (the last phase, III b) will probably make a difference, if not the difference.  

So, what about this vaccine? 

The vaccine

In fact, two studies conducted in Sierra Leone and Guinea in 2015, as the Ebola epidemic in West Africa was declining, demonstrated the efficacy of the immune response in vaccinated individuals, without serious side-effects.  

Starting another study early in this epidemic is a challenge in itself.  

There are many logistical challenges: ultra-cold chain (the vaccine must be kept for transport at a temperature of -80 degrees); accessibility (some villages are three days by motorcycle from Mbandaka, the capital of the province); climate (let's not forget that we are in the middle of the equator); and human resources (indeed the requirements of the study require vaccinators with approved medical profiles in the country).  

The poor and the kind

Vaccination as part of a clinical trial will probably make all the difference, a point of inflection. If it’s not too late already. Protecting nurses and all health care intermediaries (in this I include traditional caregivers, spiritual and religious guides, motorcycle ambulance drivers) is already a fundamental step in controlling the spread of the epidemic, because, it must be said again, people in these roles are the "amplifiers" of the disease. 

Alas, Ebola is the disease of "people who care", "people who help, who support others". It is the disease of altruism if we can say it like that. But it is also the disease of the poor.  

The knot of the problem is beginning to tighten...

Because even though we are all equally vulnerable today, there are some notable differences: if the health system is strong, powerful, and resilient it will play an important role in containing the epidemic.  

The crisis mechanisms in certain hospitals in certain countries are very different. Starting with the basic aspects: disposable gloves, disinfectant solutions, the culture of hospital hygiene, the sterilization of medical equipment ... All this in a framework of continuing training of health workers, regulated healthcare provision, follow-up and especially early detection. 

Take the washing of hands and the use of gloves. These two basics of hospital hygiene are the ABC, and the prerequisites for avoiding hospital transmission chains. But to have this in place, one must also talk about running water, soap, hydro-alcoholic solution, and, equally, culture.  

So, right now we are in a vacuum, and the knot of the problem is beginning to tighten.  Act 1. 

Bikoro

But today is a different day. The Médecins Sans Frontières vaccination team is ready take a helicopter to one of the future key vaccination sites: Bikoro. The team is waiting patiently on the airstrip for the arrival of the Minister of Health and his team, and we are flying south. Towards the other reality. 

Arrival in Bikoro. It’s strange because from the helicopter it seems like there are just a few houses here and there. But from the ground, it's a small town.  

Life here revolves around the lake that leads to the River Congo, a river-majesty that has all the honours and beliefs one can imagine. The river is responsible for everything, sometimes raised to the rank of supernatural divinity. 

 
The team, just arrived, goes directly to the work. We are beginning to clean the old primary school belonging to the Congrégation des Sœurs. We set up in the two main classes: one becomes the office, and in the other we erect the eight individual tents that will serve us as bed for tonight. The chapel will be converted into a stock room and first aid. Gradually we begin to see what our future life will look like here. 

 
It is 21h.  Lights out.  Tomorrow is another day. 

I do not have the strength to read anything, and find myself asleep, a book in my hands. The next day I would realize that I read only one page.