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Adding insult to injury: Why do healthcare professionals stigmatize victims of unsafe healthcare with accusations of sexual promiscuity?

I can’t answer the question in the title, and I don’t want an answer. What I want is that healthcare pros stop sliming suffering people with unsupported suspicions and accusations.

In a recent example of this reprehensible behavior, a senior member of Liberia’s Ebola Case Management Team speculated that a Liberian woman identified with Ebola in mid-March – several weeks after the last previous Liberian tested positive for Ebola – might have “had sex with a survivor” (

The infected woman has 5 children and a modest job – selling food in the market ( Having Ebola is a heavy burden for the woman and her family and a threat to her neighbors. For her to be slimed in public – by a government official speculating about her sexual behavior – can only add to their sorrow and confusion.

What is the most likely source of her infection? Based on more than 20 Ebola outbreaks from 1976 to 2015, if the woman has not been caring for someone with Ebola (she hasn’t), she most likely got it from attending a healthcare facility that reused instruments without sterilization. Hundreds of cases of Ebola have been documented from unsafe healthcare, while no – none, nada, zero – cases of Ebola have been traced to sex with a survivor.

Is Liberia’s Ebola Case Management Team considering the possibility the woman got Ebola from a healthcare facility? Very likely, yes. Whereas the Ebola outbreak continues in Sierra Leone and Guinea, Liberia’s outbreak is over or nearly so. Such success is evidence that Liberia’s Ebola Team is competent – that it has recognized and addressed patients’ risks to get Ebola in hospitals and clinics.

Competent, yes, and that’s important. But the Team has been and continues to be unethical in not acknowledging such risks to the public.

A similar assessment applies to experts dealing with HIV in Africa. Consider, for example, that roughly 50% of married HIV-positive women in Africa – over 80% in the Democratic Republic of Congo and Sierra Leone – have HIV-negative husbands (data from Demographic and Health Surveys available at:

Healthcare pros’ repeated assertions that sex is the source of almost all HIV infections in Africa charge all such women with extramarital sex, a charge that is a slur in many cultures. Such sliming is a de facto policy. Virtually all organizations that bankroll HIV prevention in Africa — UNAIDS, WHO, USAID, Gates, and others – require people they fund to aver that almost all HIV infections in Africa come from sex.

Many healthcare pros knowledgeable about HIV are aware of such nonsense. Those who speak out – who are both competent and ethical – have no chance to work on HIV in Africa. They are pushed aside in favor of others who are either ignorant or unethical (or both).

WHO promotes safe injections, but continues to underestimate bloodborne risks

On 23 February, WHO announced its intention to promote auto-disable syringes for curative injections[1]. This is a hugely encouraging response to an HIV outbreak discovered in Roka village, Cambodia, in December 2014 – hundreds of villagers infected through unsafe healthcare.

Unfortunately, WHO’s press release announcing its commitment to promote auto-disable syringes low-balled the risk to get HIV from unsafe health care. The press release cited a recent WHO-sponsored study[2] that estimated unsafe medical injections accounted for less than 1.3% of HIV transmissions in the world in 2010. The authors of that WHO-sponsored study calculated their estimates using a model that depends crucially on an assumed low rate of HIV transmission through contaminated syringes and needles. The authors assumed that if a doctor or nurse injects someone with HIV and then reuses the same syringe and needle – without boiling them – to give you an injection, your risk to get HIV is only 0.32%-0.64%. To support such an assumed low risk, the authors cited similar assumptions from other papers and authors – all of which ignored and/or rejected evidence of transmission during actual outbreaks where medical injections transmitted HIV.

The outbreak in Roka, Cambodia, gives us a chance to test these low-ball assumptions. If the risk to transmit HIV from an HIV-infected patient to a later patient through reused, unsterilized syringes and needles was 0.32%-0.64% only, someone infected with HIV would have to have, on average, 156 (=1/0.0064) to 313 (=1/0.0032) injections after which equipment was reused without sterilization to infect one other person. If the average person living with HIV got 15 injections per year (an absurdly large figure) it would take an average of 10 to 20 years for him or her to transmit HIV to one other person through unsafe injections. People living with HIV would, on average, die before infecting someone through an unsafe injection.

In short, with the transmission efficiencies Pepin and colleagues assumed (in the study cited by WHO’s press release), the outbreak in Roka, Cambodia, was impossible.

For decades, health care authorities who could stop transmission of HIV in health care have chosen not to do so. They have chosen to stick their heads in the sand, to accept ridiculously low assumptions about HIV transmission efficiencies through contaminated instruments, not to warn patients at risk, to give deceitful assurances, etc.

WHO’s endorsement of auto-disable syringes is a step in the right direction. Much more is required to change the trajectory of largely unnecessary and easily preventable HIV epidemics in Africa – eg, outbreak investigations, acknowledging common risks in formal as well as informal health care settings, etc.

1. WHO. WHO calls for worldwide use of “smart” syringes. Press release 23 February 2015. Available at: (accessed 24 February 2015).

2. Pepin J, Abou Chakra CN, Pepin E, Nault V, Valiquette L (2014) Evolution of the Global Burden of Viral Infections from Unsafe Medical Injections, 2000–2010. PLoS ONE 9(6): e99677. doi:10.1371/journal.pone.0099677. Available at: (accessed 24 February 2015).

Cambodian HIV tragedy: Investigate to treat, protect, and prevent HIV

On 16 December, newspapers reported more than 80 residents of a Cambodian village had tested HIV-positive in recent weeks. As of 20 December the reported number testing positive reached 140. Testing is continuing, so that number will likely increase further.

“The crisis began in late November, when a 74-year-old man from Roka tested positive for HIV at the Roka Health Center, according to a statement from Cambodia’s Ministry of Health and the World Health Organization. After receiving the result, the man then sent his granddaughter and son-in-law for testing. They also tested positive for the virus. The man then informed other villagers who had been treated by [an unregistered doctor] to get tested for HIV. After that, the number of cases steadily rose” (quote from:

Outbreaks such as this are not unusual (see: What is unusual is that this one is recognized. It will be even more unusual if it is thoroughly investigated and reported.

An investigation can limit health damage.
1. Limit damage to the victims. Test widely to find as many victims as possible. Then ensure they get good treatment so they can look forward to a near-normal life.
2. Limit damage to others. Investigate to find the specific risks so they can be stopped, not only in this village but in thousands of similar situations in Asia and Africa. Did HIV go through saline infusions, intra-muscular injections, vaccinations, what? When the routes are identified in this outbreak, tell the public at risk in Cambodia and elsewhere so they can help to develop responses to protect themselves and others.

These two challenges can be satisfied with a no-fault investigation. The investigation could be modeled on a truth commission. People who might have been involved in transmission can be asked to cooperate – to report (confess) procedures that might have been unsafe and to report who they treated – in return for a promise not to prosecute.

What can be distracting in an investigation are efforts to pin the blame on one or more people, to put them in prison or sue them. Fear closes doors – what we need are open doors to find what went wrong and fix it. Yes, there is a lot of careless behavior in clinics and hospital – but many who are careless do not realize the risks because they have been confused by lies, eg, that HIV dies in seconds outside the body.

If careless people are to be prosecuted, should we start at the top? Leaders of the health aid industry know health care is often unsafe in much of Asia and Africa and yet support the delivery of invasive procedures without warning the public and without insisting on outbreak investigations to find and stop careless errors. Since it’s unlikely anyone will try to prosecute people at the top, let’s not scapegoat people at the bottom for careless behavior.

A good example of a failed investigation is what happened in Jalalpur Jattan, Pakistan, six years ago (see: In 2008, a local NGO tested 246 people in the community, finding 88 to be infected. This got the attention of Pakistan’s National Institute of Health, which assigned Pakistan’s Field Epidemiology & Laboratory Training Program (FELTP) to investigate, with assistance from the US Centers for Disease Control and Prevention (CDC). The Government charged FELTP to: “determine the extent and chain of transmission” and to “identify…sites of potential transmission.”

FELPT’s investigators did neither. They began with a list of 20 HIV-positive people provided by the government hospital, traced relatives, and looked for people with stigmatized behaviors (sex work, male-male sex, injection drug use). Because the “investigation” did not test the general population it could not determine the extent of transmission or sites of transmission. The report added insult to injury with stigmatizing sexual fantasies: “there may be hidden extramarital and unsafe sexual practices in the community which were difficult to unveil” (see p 51 in:

In Cambodia, let’s hope for an investigation that prioritizes finding and caring for victims (see: and preventing more victims – and that does not insult victims with accusations of stigmatized behaviors.

Good news from Liberia: Why?

Reported deaths from Ebola peaked in Liberia in the week ending 2 September,[1] falling to 35 per day during 12-18 October (see WHO Situation Reports for 15 and 25 October[2]). As early as 9 October, National Public Radio in the US noted that reported Ebola cases in Liberia had fallen by “about 160 cases each week” from end-September.[3] According to a 23 October news report,[4] “Virtually everyone in Liberia agrees on a new, stunning fact: Ebola cases in Liberia are dropping.”

Why has the outbreak apparently peaked and fallen back in Liberia, while the outbreak in Sierra Leone has stampeded ahead for at least another month? The answer to that question is relevant to ongoing and anticipated well-funded public health interventions aimed at the outbreak.

Gene studies suggest Ebola has been around for at least 1,200 years[5] and possibly much, much longer.[6] Presumably thousands of Africans over the centuries have gotten Ebola from the wild, eg, by getting blood into cuts while butchering infected chimpanzees. The absence of recognized outbreaks before 1976 is strong evidence transmission during home-based care and funerals is not enough to sustain, much less amplify, outbreaks. Before 1976, people that were somehow infected with Ebola on average infected less than one other person.

Similarly, in well-documented Ebola outbreaks beginning in 1976, transmission within the household and during funerals has not been enough to sustain outbreaks. Amplification of infections in health care settings – transmission from patients to care-givers and to other patients – has multiplied otherwise rare infections to the point that outbreaks are recognized.

Once recognized, most of the more than 20 outbreaks to date ended within 1-3 months.
Only one continued beyond 4 months – an outbreak, in Gabon in 2001-2, continued 5 months and 5 days.[5] The common pattern of interventions ending outbreaks to date has been to somehow stop health facilities from amplifying infections – to prevent Ebola transmission to health care workers and other patients.

A mission hospital near the Ebola River in Zaire amplified the eponymous Ebola outbreak in 1976. Injections with reused and unsterile syringes and needles infected at least 85 of the 280 who died[7] and – through secondary infections among contacts – were directly or indirectly responsible for most deaths. The hospital closed after Ebola sickened or killed most of its staff. Although this was a sorry way to stop the hospital from further amplifying the outbreak, it was effective. After the hospital closed, the outbreak ended with home-based care before an international health aid team even began to search for cases.

During the ongoing West Africa outbreak, the health aid community has acknowledged that hospitals are dangerous places for health care workers. WHO’s Situation Report for 22 October[2] reports 440 cases and 244 deaths among health care workers in West Africa and Nigeria through 19 October. The health aid community has commendably committed hundreds of millions of dollars in equipment and training to stop transmissions to health care staff.

However, to stop hospitals from amplifying infections, patients and not only health care workers must be protected – eg, instruments must be sterilized and gloves changed between patients. If anything is being done along these lines, there is no news. The health aid community has said next to nothing about transmissions to patients in Guinea, Liberia, and Sierra Leone – has any account been made but not reported? – and Ebola prevention messages for the general public have been silent about patients’ risks. Better reporting from Nigeria very clearly shows hospital amplification to health staff and patients: An index case flying in from Liberia started a mini-outbreak that infected 19 Nigerians – 16 acquired Ebola during health care (12 health staff and 4 patients) and 3 of these 16 infected one relative each.[8]

Even if public health authorities are silent about patients’ risks to get Ebola during health care, people will learn of such infections through friends and rumors. When people avoid health facilities because they fear to get Ebola, or don’t want to be cremated or buried in unmarked graves, this reduces amplification of infections in health facilities. When doctors and nurses stay home or refuse to treat patients out of fear, this also protects patients. Some anecdotal reports suggest that such behaviors have been common in Liberia.

Previous Ebola outbreaks warn that health care in hospitals, not home-based care, is the biggest risk to sustain and amplify outbreaks. How much has public avoidance of health care facilities contributed to reducing Ebola transmission in Liberia? Conversely, how much did public health efforts to bring suspected and confirmed cases into hospitals beginning in March contribute to outbreak amplification in Liberia through August?

Maybe the current outbreak in West Africa is different – maybe patients cared for at home are responsible for outbreak amplification, while hospitals have been dampening the outbreak. Maybe. On the other hand, if transmission during this outbreak is similar to previous outbreaks, the massive funds provided to stem the epidemic present a promise and a threat. If patients are protected, aid-financed expansion of health facilities could save lives. On the other hand, if patients are not protected, bringing more suspected and confirmed cases into hospitals could impede rather than speed the end of the outbreak.

5. Chippaux, Outbreaks of Ebola virus disease in Africa…, available at:
6. Taylor et al, Evidence that ebolaviruses…Miocene, available at:
7. International Commission, Ebola haemorrhagic fever in Zaire, 1976, available at:
8. Fasina et al, Transmission dynamics…Nigeria, available at:

How is Ebola transmitted in the ongoing West African outbreak?

Getting an answer to the question in the title is crucial for people in countries with ongoing epidemics – to protect themselves they need to know the ways they are most likely to get Ebola. The answer is important for people in other African countries as well – to help them assess the probability the epidemic will reach their country, and to prepare for this possibility.

People outside Africa also need the answer. Politicians and bureaucrats who vote and manage aid funds can make better decisions with a clear account of whether and how what they are paying for is saving lives. Finally, although there is only an outside chance the virus has changed or will change to transmit more efficiently, that small possibility represents big risks to people around the world. We want to know what’s happening.

There are two steps for health aid managers to answer the question in the title. They must:
• Get the answer through surveillance.
• Report what they find to the general public.

As of September 2014, public health experts have not reported the relative contribution of various exposures in transmitting Ebola in the current outbreak. Their failure to do so may be due to missing the first step (ie, they don’t know) or the second (ie, they know but don’t say).

Contact tracing to find the source of infections

The public health response to West Africa’s Ebola epidemic includes a lot of effort to trace contacts of people with Ebola to identify new cases as soon as possible – as soon as they get symptoms. For example, at end-August, “WHO and its partners are on the ground establishing Ebola treatment centres and strengthening capacity for…contact tracing…” (WHO, Ebola virus disease update, 28 August, at:

However, I have found no reports of contact tracing to find where and how people with Ebola got their infections. How to do this is straightforward: Ask people with new Ebola infections if they had touched someone who was sick or if they had attended a funeral in the previous 21 days; touching someone sick or dead with Ebola is a recognized risk. Ask if they got injections, infusions, or any other skin-piercing procedure in the previous 21 days; such procedures are also recognized risks. Then trace contacts and visit and investigate reported health care settings.

If more than a few people with new infections report no contacts with other cases and no skin-piercing procedures, that is cause for concern and, more critically, further investigation. Such unexplained cases could be showing the virus is transmitting in unexpected ways.

John Potterat has been a practitioner and advocate of contract tracing and partner notification as a public health tool to understand and control the spread of infectious diseases. In a recent article on partner notification for HIV in Africa, written before the explosion of West Africa’s Ebola outbreak, Potterat presciently recommends the skills required to diagnose what has allowed that outbreak to grow: “Nurturing public health investigatory (and people and community rela¬tions) skills that one can acquire by conducting PN [partner notification] would be of great service anywhere that new communicable infections or public health emergencies are likely to emerge” (–article-a4370-abstract).

Telling people what is happening

This second step to answer the question in the title is not automatic. Based on reports from previous Ebola outbreaks, patient-to-patient transmission in health care settings – eg, through injections with contaminated syringes and needles – contributes to expanding outbreaks. Considering the persistent expansion of the ongoing Ebola outbreak in West Africa, it is probable that patient-to-patient transmission plays an important part. If anyone has such information, they have not disclosed it.

In Africa, it has been common practice for ministries of health – encouraged by health aid managers – not to disclose evidence that patients have gotten blood-borne infections such as HIV from unsterile health care procedures. Not warning the public is excused by the assertion that warning might cause more harm than it would prevent: the infections prevented would be outweighed by disease and death due to patients avoiding health care.

Such body count calculations ignore doctors’ ethical obligations. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient avers: “1d. Quality assurance should always be a part of health care… 9. Every person has the right to health education that will assist him/her in making informed choices about…the available health services…” (see:

Furthermore, the assertion is based on a misleading mention of only two options – no health care vs. unsafe care. But there is a third option – safe care. Getting to the third option is not, primarily, a matter of money. It costs little or nothing to avoid unnecessary invasive procedures, shift to oral medication, boil instruments, or use plastic disposables. What is lacking is public awareness – lacking due to misinformation by ministries of health and health aid managers.

If ministry officials and/or health aid managers have evidence that people have gotten Ebola infections from health care procedures and settings during the current outbreak, will they tell the public?

Will concern to stop West Africa’s outbreak over-ride public health managers’ unwillingness to warn the public about risks in health care settings? Will the world public’s interest to know if the virus is changing over-ride health aid managers’ unwillingness to acknowledge the contribution of unsafe health care to the current outbreak?

Intersection between HIV and Ebola in Africa

A long history of unsafe health care

During the 20th century and continuing, millions of Africans have gotten blood-borne infections, including tetanus, hepatitis B, hepatitis C, HIV, and Ebola, from unsafe healthcare. With some exceptions, the health aid community’s response has been to deny that health care accounts for more than minorities of blood-borne infections. Instead of fixing unsafe procedures, the health aid community’s repeated response has been to promote solutions involving more invasive procedures.

For example, women and infants in Africa were observed to get tetanus infections from unsterile and contaminated instruments during childbirth. The health aid community responded with tetanus vaccinations – arranging for young women to get as many as five more injections, and for babies to be injected at birth. Vaccinations protect mothers and babies from tetanus, but because additional injections are not reliably sterile, an unknown number get other blood-borne infections.

Across much of Africa in the late 20th century, 70%-95% of adults had been infected with hepatitis B at some time in their lives, while 7%-15% had continuing (chronic) infections. Most chronic infections came from exposures during infancy or early childhood. Studies in Africa reported as many as 50% of children infected before their 5th birthday. The health aid community denied an important role for unsterile health care. Instead of making sure children received safe care, the health aid community introduced another injected vaccine to protect them from hepatitis B. Vaccinations currently protect many Africans from hepatitis B but increase their risk for other blood-borne infections.

Enter HIV. Recent mainstream research traces the origin of the world’s HIV epidemic to colonial health care programs spreading a rare HIV infection (from an otherwise self-limiting outbreak, likely beginning from a chimp butchered for bush meat) to thousands of Africans through unsterile injections for sleeping sickness, yaws, and suspected sexual infections. A lot of evidence suggests blood-borne transmission continues to drive Africa’s peculiar HIV epidemics. Unlike epidemics in almost all countries outside Africa, women in Africa are infected more often than men. Outside Africa, HIV is rare except in adults who inject illegal drugs and men who have sex with men; whereas in much of Eastern and Southern Africa, as many as 20%-50% of adults, most with conservative sex lives and often an HIV-negative spouse, can expect to get HIV during their lifetime.

Missing an opportunity to find and fix unsafe health care

In 1988, Russia investigated an unexplained HIV infection in a child with an HIV-negative mother – thereby uncovering and stopping a chain of transmission through unsterile procedures in 13 hospitals that spread HIV from one to 265 children in 15 months. Several years later, tests in four African cities (Kampala, Kigali, Lusaka, and Dar es Salaam) on 5,593 inpatient children and their mothers found 61 children (1.1%) to be HIV-positive with HIV-negative mothers. Instead of initiating investigations, WHO staff blithely and incredibly concluded “the risk of…patient-to-patient transmission of HIV among children in health care settings is low” (p. 85, 1992-1993 Progress Report, Global Programme on AIDS).

The health aid community has spent billions on HIV prevention messages for Africans focusing almost exclusively on sexual risks. Such messages, with their roots in European and American racial prejudices, smear all Africans – including millions of HIV-positive married women with HIV-negative husbands – with suspicions of uncontrolled sexual behavior.

Although the health aid community has done its best to ignore HIV from unsafe health care in Africa, the US Congress has not only been aware of the problem, but has also made available billions of dollars to fix it. In 2003, the US Congress pressed USAID and CDC to spend $300 million allocated for HIV prevention to improve injection safety and blood safety, primarily in Africa. In 2008, when Congress approved $48 billion for HIV aid, primarily for Africa (see:, it asked the President to develop a 5-year strategy, including (page 8): “(C) promoting universal precautions in formal and informal health care settings; (D) educating the public to recognize and to avoid risks to contract HIV through blood exposures during formal and informal health care and cosmetic services; (E) investigating suspected nosocomial infections to identify and stop further nosocomial transmission…”

At the same time, Congress (page 39) asked the US Global AIDS Coordinator to submit an annual report assessing impact on “capacity to identify, investigate, and stop nosocomial transmission of infectious diseases, including HIV and tuberculosis…” Regrettably, during 2008-13, USAID and CDC spent nothing on outbreak investigations in Africa or to warn the public about blood-borne risks. Instead, USAID and CDC promoted more invasive procedures – male circumcision in unreliably sterile conditions – to reduce HIV infections.

Ebola shines a spot-light to unsafe health care

In 2014, West Africa’s Ebola outbreak exposed unsafe health care systems. Health aid managers were quick to acknowledge that health staff are at risk – this was impossible to deny as more than 100 doctors and nurses died. On the other hand, health aid managers have been silent about patients getting Ebola from unsafe health care.

Health aid managers have for decades been able to get away with a head-in-the-sand response to HIV from unsafe health care. This has been possible because HIV infections from health care are relatively easy to ignore – most victims don’t recognize their infections, which are silent for years. Even when unsafe health care fuels atrocious HIV epidemics, health aid managers have been able to divert attention, adding insult to injury, by blaming infections on victims’ supposed sexual misbehaviors.

With Ebola as with HIV, health aid managers are faced with the choice between warning the public to be wary of skin-piercing health care procedures or staying silent about the risk and thereby allowing preventable infections. With HIV, health aid managers’ have chosen to deny problems, even at the cost of millions of unnecessary infections. With Ebola, however, health aid managers may not have that option. People who see family members, friends, and neighbors get Ebola within days after health care procedures may demand action to find and stop unsafe health care procedures.

If West Africa’s current Ebola outbreak gets people to see and stop reuse of unsterile instruments in health care, the beneficial consequences of the current outbreak – fewer HIV and other blood-borne infections – could far outweigh its current terrible human costs.

To stop Ebola: Tell people about bloodborne risks and treat them with respect

With recent US and WHO statements and commitments, the health aid community is escalating the war on Ebola in West Africa. That’s good news. But I’m still worried. Escalation does not necessarily lead to success, especially if health aid managers escalate failed strategies. Two errors in the response to date have been:
• Not warning the public about risks to get Ebola during invasive health care. This error may well be the principle cause of the continuing increase in numbers of infections.
• Not respecting patients’ rights to choose where to be treated. This error breeds public distrust, undermining cooperation. A strategy to stop Ebola that does not rely on and respect the public is like trying to clean up a puddle with a hammer. The health aid community should switch to towels – to a softer approach.

Based on experience from past outbreaks, as soon as health aid managers fix these errors, we can expect a sharp fall in numbers of new infections, with the outbreak ending in a matter of weeks to months. To fix these errors, public health programs should:

1. Warn people that injections, infusions, and other skin-piercing procedures can spread Ebola, and to avoid such procedures as much as possible

An important observation from earlier outbreaks is that Ebola transmission in health care settings amplifies what is otherwise a self-limiting outbreak. Transmission during home-based care, even with some dangerous funerals, has not been enough to sustain an outbreak. Aside from what happens in the community, preventing any additional (“excess”) transmissions in health care settings has been enough to stop previous Ebola outbreaks.

Most transmissions in health care settings fall into two categories – transmissions from patients to health care workers, and patient-to-patient transmissions. In the current West African outbreak, health aid managers have addressed doctors’ and nurses’ risks to get Ebola from patients by providing protective gear such as gloves and aprons. However, health aid managers have been silent about patient-to-patient transmission, especially through reuse of unsterilized skin-piercing equipment for injections, infusions, and other procedures. This “oversight” may be the error that allows continuing “excess” transmissions in health care settings to amplify what would otherwise be a receding outbreak.

The urbanization of the current outbreak makes it especially important to warn the public to avoid invasive procedures with unreliably sterile instruments. In rural areas, where most Ebola outbreaks have been observed to date, options for invasive procedures are limited. But in towns and cities, where many who are infected with Ebola currently live, people can get injections, infusions, and other skin-piercing procedures from scores of enterprising healers in formal and informal sectors, including pharmacists, private clinics, quacks, etc.

How to stop “excess” patient-to-patient transmissions during invasive procedures? In theory, public health managers could assure that health care is safe by educating and supervising doctors and nurses. However, health care in the affected countries in West Africa was not safe for patients even before the current Ebola outbreak. With the outbreak further stressing the system and reducing available staff, health care is even less safe than in “normal” conditions. To stop transmission of Ebola during invasive procedures, there is no option except warning the public. That is also the only ethical option.

2. Demonstrate respect for the public by letting people choose where to be treated and by acknowledging risks in health care settings, including Ebola isolation wards

The World Medical Association’s Declaration of Lisbon on the Rights of the Patient (available at: presents guidelines for doctors to respect patients. According to article 3: “The patient has the right to self-determination, to make free decisions regarding himself/herself… A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy…” such as, for example, entering an Ebola isolation ward vs. taking treatment at home.

Ebola response teams in West Africa have violated patients’ rights by coercing them to enter isolation wards. When health agencies allow Ebola suspects and even cases to choose treatment at home, it frees money and staff to give better treatment to remaining inpatients and to improve community outreach. Based on previous outbreaks, home treatment results on average in less than one new infection for each current case – which is all that is required to stop the epidemic.

Giving suspected cases and their families the option to treat at home will defuse tension between health care personnel and the general public. Healing this rift is essential to allow public health authorities to gain accurate information about the epidemic. People who are not afraid are more likely to talk.

Lessons from three previous Ebola outbreaks

Newspapers, web, and TV have been delivering a crescendo of reports and comments on West Africa’s Ebola epidemic. A lot of what is available for public consumption scares people who are not at risk. At the same time, people at risk are not getting adequate advice from official sources to make informed decisions about how to protect themselves and their loved ones.

In this situation, it’s useful to take a look back at three well-studied and well-reported Ebola outbreaks: the first two recognized outbreaks in 1976 in Sudan and Zaire (currently Democratic Republic of the Congo) and a later outbreak in Kikwit, Zaire, in 1995. Official committees of experts studied each of these outbreaks and reported what they found in the Bulletin of the World Health Organization in 1978 and in the Journal of Infectious Diseases in 1999.

Nzara and Maridi, Sudan, 1976

The first recognized Ebola outbreak began in Southern Sudan in late June 1976 and ended in November 1976. A WHO/International Team coordinated a detailed and thorough investigation of the outbreak, reporting 284 cases and 151 deaths. Information and quotes in this and following paragraphs are from: Bulletin of the World Health Organization, 1978, pp 247-270, available at: (accessed 2 August 2014).

The outbreak in Southern Sudan was traced to infections among workers at a cotton factory in Nzara town beginning in late June. The source of the virus is suspected to be bats or other animals living in the factory. During the outbreak, 9 factory workers got ill with Ebola (p 253); most subsequent infections came from household contact. “The outbreak in Nzara died out spontaneously” (p 254) after 31 deaths. Before the Nzara outbreak ended, cases from Nzara spread Ebola to two other communities, Tembura and Maridi. In Tembura, a woman from Nzara introduced Ebola that killed three close contacts; that was the end of it in Tembura. In Maridi, Ebola spread from two people from Nzara treated at Maridi’s hospital, which “served both as the focus and the amplifier of the infection” (p 252). Transmissions in Maridi lead to 116 deaths. Several patients from Maridi went for treatment in Juba, resulting in one additional infection and death among Juba’s hospital staff.

“The difference between the Nzara and the Maridi outbreaks is best exemplified by examining the focus where patients most probably became infected. Few patients (26%) were even hospitalized in Nzara, and they seldom stayed more than a few days, but in Maridi almost three-quarters of the patients were hospitalized, and often for more than two weeks. As a result, Maridi hospital was a common source of infection (46% of cases), whereas the Nzara hospital was not (3% of cases)…” (p 253).

A WHO/International Study Team arrived in Maridi towards the end of the epidemic and stayed to the end. The Study Team recruited surveillance teams to scout for cases in communities around Maridi. “A large number of cases of active infection were soon discovered; each was reported to the Sudanese officials and an ambulance accompanied by a Public Health Officer was sent to the house. Patients were persuaded to enter the isolation wards at the hospital” (p 250). Significantly, Public Health Officers did not force suspected cases to go to the hospital: “Some refused, and in these cases relatives were warned of the grave risks, and advised to restrict close contact with the patient, and to limit it to only one close relative or friend. Protective clothing was offered but usually refused.”

Yambuku, Zaire, 1976

The first recognized case reported symptoms on 1 September. The last death occurred just over two months later on 5 November 1976. An International Commission managed a detailed and thorough investigation of the outbreak, reporting 318 cases and 280 deaths. The information in this and following paragraphs is from the Bulletin of the World Health Organization, 1978, pp 271-293, available at: (accessed 2 August 2014).

“The index case in this outbreak had onset of symptoms on 1 September 1976, five days after receiving an injection of chloroquine for presumptive malaria at the outpatient clinic at Yambuku Mission Hospital… [A]lmost all subsequent cases had either received injections at the hospital or had had close contact with another case. Most of these occurred during the first four weeks of the epidemic, after which time the hospital was closed, 11 of the 17 staff members having died of the disease…” (p 271).

“Five syringes and needles were issued to the nursing staff [at the Yambuku Mission Hospital] each morning for use at the outpatient department [with an average of 200-400 outpatients each day], the prenatal clinic, and the inpatient wards [with 120 beds]. These syringes and needles were apparently not sterilized between their use on different patients but rinsed in a pan of warm water. At the end of the day they were sometimes boiled” (p 273).

“The epidemic reached a peak during the fourth week, at which time the YMH [Yambuku Mission Hospital] was closed [on 3 October], then it receded over the next four weeks” (p 279). “[I]t seems likely that closure of YMH [Yambuku Mission Hospital] was the single event of greatest importance in the eventual termination of the outbreak” (p 280). The last recognized transmission occurred in late October.

The International Commission organized surveillance for cases in communities around Yambuku. “Suspect cases were not closely examined, but medicines were given to them and arrangements were made for their isolation in the village… [P]hysicians were sent to follow up suspect cases…” (p 276). Notably, surveillance teams did not force or even urge suspect cases to go to hospital. In any case, the outbreak in and near Yambuku had already died out on its own, with the last probable case dying on 5 November, four days before surveillance began on 9 November (p 277).

The International Commission collected and reported data on transmission from cases to family members. In 146 families with one or more cases acquired from outside the family, 1,103 family members were exposed, of which 62 (5.6%) got sick with Ebola (p 282). In other words, there was less than a 50% chance a case would infect a family member (146 cases, or more if any family had more than one case, infected a total of 62 family members). Thus, once the hospital closed, each case infected on average less than one family member, so the epidemic died out on its own.

Kikwit, Zaire, 1999

An International Scientific Commission investigated an Ebola outbreak in Kikwit, DRC, a large, sprawling town with a population reported at 200,000-400,000 at the time of the outbreak. The investigation identified 315 cases between 6 January and 16 July; out of 310 cases with adequate information, 250 died. Information in this and subsequent paragraphs is from a 1999 special issue of the Journal of Infectious Diseases, available at: (accessed 3 August).

During the Kikwit outbreak, 80% of case patients were hospitalized to treat their Ebola illness (page S82). However, hospitalization did not interrupt contacts between family members and case patients (p S88): “As in much of Africa, the families of inpatients are responsible for providing food and many other aspects of patient care, such as cleaning bedpans and washing soiled clothing and linens. Often family members arrange to sleep on the hospital ward [even sharing the patient’s bed; p S90] to assure continued care through the night.”

A study of secondary infections among 173 household members of 27 case patients found 28 secondary infections in 15 households (7 had >1 secondary case). “The exposure that was most strongly predictive of risk for secondary transmission was direct physical contact with the ill family member, either at home in the early phase of illness or during the hospitalization” (p S89). The 28 secondary cases occurred in 95 household members who had touched the case patient during early or late illness; whereas none of 78 household members who had not touched the patient at that time got sick, even though many slept in the same room, shared meals, or touched the patient before illness (p S89).

“There was an additional risk associated with a variety of exposures to patients in the terminal stages of illness, such as sharing a hospital bed or hospital meals and touching the cadaver” (p S90). “[T]he use of barrier precautions by household members and standard universal precautions in hospitals would have prevented the majority of infections and deaths…” (p S91).

During case surveillance in and around Kikwit town (p S78), “persons who met the case definition…were instructed to seek medical evaluation and possible hospitalization at Kikwit General Hospital…” However, this was not forced; if the sick person chose to stay home, family members “were educated on how to reduce their risk of infection…. Nurses previously trained in the sentinel clinics also visited household of probable case-patients to distribute protective materials (eg, a pair of gloves, soap, and wash basin) as needed and to reinforce educational messages about risks of transmission and symptoms suggesting disease in subsequent family members.” During surveillance outside Kikwit (p S78-S79), “Probable case-patients were confined in their households, instructions for care were given, and basic protective equipment was provided to the primary care givers.”

Lessons for West Africa, 2014

Based on reports from previous epidemics, here are several recommendations. The first is for people at risk to protect themselves. The second is for public health managers to deal with cases in a way that is acceptable to the community while at the same time ensuring transmission is too low to sustain the outbreak. Stopping the outbreak involves reducing the average transmission from each current case to less than one more case. Both recommendations contribute to that goal.

1. Recommendation to the public: If you are living in a community with Ebola cases, avoid injections, infusions, dental care, manicures, and all other skin-piercing procedures with instruments that might not have been sterilized after previous use. If you do this, and if you stay away from people with suspected Ebola infections, you have virtually no risk to get Ebola.

If someone stays away from sick people and funerals, the only remaining risk to get Ebola is through unrecognized contact with some unknown case. In previous epidemics, acquisition of Ebola from unrecognized contacts with unknown strangers has been confirmed through only one form of contact – blood-to-blood contact when health care workers reuse syringes and needles without sterilization to give injections to one patient after another. Reused, unsterilized skin-piercing equipment can pass Ebola from someone with the virus to complete strangers. If people in communities with Ebola avoid skin-piercing procedures – in hospitals, pharmacies, dental clinics, barbershops, beauty salons, from traditional healers, etc – the risk to get Ebola from some unknown source is near zero. Moreover, the public health risk – that people with Ebola will infect strangers not involved in patient care – will be too low to sustain the outbreak. (If you do go for an injection, manicure, or other skin-piercing procedure, you can ensure instruments used on you are sterile by following advice at:

2. Recommendation to public health managers: Accept and accommodate home-based care of suspected and even confirmed cases, if that is what the family wants.

For the sake of effective management of the epidemic, the challenge is to reduce transmission on average from each case to less than one more case. Based on reports from three well-studied outbreaks in 1976 and 1995, caring for an Ebola case at home results on average in less than one new case – that is enough to wind down the epidemic, which is a lot better than what has been achieved so far in West Africa in recent months.

If a suspected case with common symptoms (fever, diarrhea, sore throat) goes to the Ebola ward, what is the chance he or she does not have Ebola? If so, what is the chance he or she will get Ebola from another patient? Without good data showing near zero risk for patients to get Ebola in an Ebola ward, it is reasonable for people to fear and resist going there. And, because getting all cases into isolation wards is not necessary to stop the epidemic (see previous paragraph), there is no good public health excuse for using government coercion to force people to go. Can we expect parents willingly to send children with sore throats to isolation wards?

The risk to family care-givers is, nevertheless, substantial if the suspected case turns out to have Ebola. If families accept the risk, that’s their choice. However, that risk can be reduced by giving care-givers detailed advice about specific risks, providing protective gear, and advising in-house quarantine measures to protect family members and others.

In any case, forcing suspected cases to go to isolation wards is likely to undermine rather than enhance epidemic control. Consider: When people are afraid government will force them or their loved ones to go to an Ebola ward, they may hide sick family members (suspected cases), avoid public health personnel, and seek secret treatment from cooperative doctors or others who may or may not practice barrier nursing or sterilize instruments after use. Thus, the threat of force may well reduce, not enhance, the ability of public health managers to advise and to supervise treatment of cases to prevent onward transmission.

This recommendation to accommodate home-based care agrees with a recent decision by Sierra Leone’s President Ernest Bai Koroma to quarantine sick patients at home, a decision appreciated by Heinz Feldman at the US National Institute of Allergy and Infectious Diseases: “It could be helpful for the government to have powers to isolate and quarantine people and it’s certainly better than what’s been done so far…” See: West African outbreak tops 700 deaths, Associated Press 31 July 2014, available at: (accessed 31 July 2014).

Risks the current outbreak will spread to other countries

Are people living in the US or UK or Australia at risk? No. Just as in Maridi, Sudan, in 1976, the risk is that a patient with Ebola acquired elsewhere will go to a hospital with poor infection control, and that the hospital will amplify the infection, spreading it into the community. This is not going to happen in Europe, the US, or most other countries because hospitals with adequate infection control will not amplify the outbreak.

However, there is a risk that Ebola from West Africa’s ongoing outbreak might spread to other countries in Africa. Wherever HIV, a slow-acting bloodborne virus, transmits through unsafe healthcare, there is a risk that Ebola, with an incubation period of weeks not years, will similarly spread through unsafe healthcare. Most countries in Africa have generalized HIV epidemics, with more women than men infected, and with only small minorities of infections explained by men having sex with men or people injecting illegal drugs. The public health community likes to blame Africa’s generalized epidemics on sex, but no one has been able to find sexual differences between Africa vs. Europe or the US that could explain Africa’s generalized HIV epidemics. What is different is that Africans get more exposures to reused but unsterilized skin-piercing instruments during health care and cosmetic services.

The existence of generalized HIV epidemics in a country is best explained by a lot of HIV transmission through unsafe health care along with some sexual transmission. The fear that Ebola from West Africa might spread to other countries is a realistic concern for countries with generalized HIV epidemics.

Today’s denialists undermine HIV prevention and stigmatize Africans with HIV

Yesterday’s AIDS denialists claimed HIV did not cause AIDS. With insignificant exceptions, that stupid belief has gone the way of the dodo. Although that belief was all over the internet, it had little influence on policy except in South Africa, where it delayed government support for anti-retroviral drugs to prevent mother-to-child HIV transmission and to treat HIV infection.

Today’s denialists accept that HIV causes AIDS but they deny – despite evidence to the contrary – that a large proportion of Africans infected with HIV got it from blood through skin-piercing procedures in health care and cosmetic services. Today’s HIV-from-blood denialists are influential and dangerous:
• They draft and fund HIV prevention messages that ignore risks in skin-piercing procedures.
• They stigmatize HIV-positive Africans and threaten them and their families by blaming them for sexual misbehavior.
• They promote racist stereotypes of African sexual behavior by claiming that most African adults with HIV (more than 200 in 1,000 in several countries) got it through heterosexual sex (whereas elsewhere in the world less than 1 in 1,000 adults gets HIV that way).
• They mismanage research to avoid unwanted results; researchers who are denialists do not ask about or report skin-piercing procedures as risks for HIV.

In sum: today’s HIV-from-blood denialists contribute to Africa’s continuing high rates of HIV infection. Whereas most of yesterday’s denialists were outside the medical profession and had little money to play with, today’s HIV-from-blood denialists are led by medical professionals in WHO, donor governments, and leading universities. Medical professionals have a conflict of interest when it comes to Africa’s HIV epidemics: Recognizing and admitting infections from blood on skin-piercing instruments would motivate and empower the public to demand safer and better health care. Health care professionals divert critical attention by blaming infections on victims’ sexual behavior.


More junk science underestimating HIV from medical injections

AIDS experts still haven’t figured out what is different about Africa that can explain why HIV epidemics there are so much worse than elsewhere. The continuing failure to find what is different exposes persistent (intentional or natural) incompetence on the part of respected researchers.

Specifically, scores of studies that have tested, followed, and retested hundreds of thousands of HIV-negative Africans to find when and how they get HIV have failed to trace the source of observed new infections.[1] Without tracing the source, there is no way to say infections came from sex – but “HIV from sex” is nevertheless the conclusion (and racist slur) from decades of incompetent, incomplete research. When such studies find people with new HIV infections who report no possible sexual exposure to HIV, researchers characteristically reject the evidence: “hmmmm, an African with HIV…must have lied about sexual behavior….”

With that “scientific” method, the US National Institutes of Health and UK’s Medical Research Council could save money by paying researchers sitting in offices in Baltimore, US, or Oxford, UK, to make up data to fit pre-determined conclusions. That would be more efficient than paying them to go to Africa, collect data, and then reject what doesn’t fit desired conclusions.

While funders have avoided funding good science to explain Africa’s HIV epidemics – for 30 years and counting – they have been all too happy to fund junk science that will get the desired results. One popular junk-science strategy to get desired results has been to model Africa’s HIV epidemic with unreliable parameters and weak, selected, or made-up data.

The latest paper by Pepin and colleagues[2] falls into that category of junk science – presenting a model with unreliable parameters and data, and using results from the model to claim that unsafe medical injections accounted for less than 1% of new HIV infections in Africa in 2010 (8,000-16,000 from injections vs. 1.9 million total new infections[3]).

Several obvious problems with the estimate are as follows:

1. Pepin’s assumed rate of HIV transmission through a contaminated syringe or needle – 1 in 150-300 injections – is far too low to allow observed HIV outbreaks through health care in Russia, Romania, Libya, and elsewhere. If those outbreaks occurred – they did! – then Pepin’s proposed rate of HIV transmission through injections is misleadingly low. For example, in Russia in 1988-89 hospital procedures passed from HIV from 1 child to more than 260 children in 15 months. Most transmissions in this outbreak came from children who had been infected less than 6 weeks earlier – enough time for infected children to get dozens but not 150-300 skin-piercing procedures followed by reuse of unsterilized instruments.[4]

2. Pepin’s same model estimates 4,300-8,500 new hepatitis C virus (HCV) infections in Africa from unsafe injections in 2010, less than 1% of estimated new HCV infections (cf: an estimated 18 million Africans were living with HCV in 2005[5], which corresponds to approximately 1 million new infections per year). Because virtually all new HCV infections come from blood, not sex, it’s likely that unsafe injections account for a lot more than 1% of new HCV infections – and by extension, more than 1% of new HIV infections as well. Furthermore, other skin-piercing procedures aside from injections likely account for a lot of new HCV infections – and by extension a lot of new HIV infections as well.

3. Pepin’s estimates distract from facts that need answers. Why do 16%-31% of HIV-positive children in Mozambique, Swaziland, and Uganda, have HIV-negative mothers (among children with tested mothers)?[6] Why do so many mutually monogamous couples find that one or both partners are HIV-positive?

In his conclusion, Pepin commendably recognizes “other modes of iatrogenic transmission” including[2]: “use of multi-dose medication vials, phlebotomies with re-used needles, dental care with improper sterilisation of instruments, unscreened transfusions, ritual scarifications and circumcisions performed by traditional practitioners… Better measurement of such exposures and of their impact on viral dynamics is an essential first step…”

Even so, Pepin does not hit the nail on the head. What is required to measure the “impact [of such procedures] on viral dynamics” is to trace HIV infections to their source. When infections are traced a hospital, dental clinic, tattooist, etc, then continue with outbreak investigations to determine the extent of the damage from unsafe health care or other skin-piercing procedure.


1. Gisselquist. Randomized controlled trials for HIV/AIDS prevention in Africa: Untraced infections, unasked questions, and unreported data. Available at: (accessed 14 June 2014).

2. Pepin et al. Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010. PLOS one 2014; 9: 1-8. Available at: (accessed 14 June 2014).

3. Annex table 9 in: UNAIDS. Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access, progress report 2011. Available at: (accessed 15 June 2014).

4. See:

5. Hanafiah et al. Global epidemiology of hepatitis C virus infection. Hepatitis 2013. Available at: (accessed 14 June 2014).

6. See pages for Mozambique, Swaziland, and Uganda at:; see also: