Why did Ebola not take off in Mali?

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I was at a dinner party in Bamako when news broke that an imam from Guinea had died of Ebola in the city’s largest private hospital. A day earlier, Mali had declared itself free of Ebola after a 2-year-old girl who had died of the disease did not infect anyone.

The case of the imam was significantly more worrying. As the details filtered in, the dinner party lost momentum, and we turned to our phones and journalist friends to get more information.

This is what happened: the imam was already sick when he entered Mali. He did not use the main border checkpoint at Kouremale. Instead, he tried to enter Mali at a smaller crossing on a dirt road. He was initially turned away, asked to return to Kouremale for a health check.

A local village chief intervened on the imam’s behalf, insisting that the border guards let him through. They did. The imam then went to Clinique Pasteur, Bamako’s largest private hospital, considered by many to be the best medical facility in the country. At Clinique Pasteur, the imam’s Ebola went undiagnosed. Instead, he was thought to be suffering from kidney disease.

There are all sorts of theories on what went wrong here, from incompetence to cover-up – Clinique Pasteur holds/held many large contracts with the UN and others, and a case of Ebola is never good for business. No investigation has been conducted yet, so we can’t comment on what really happened.

This we do know: the imam died. He was never properly diagnosed. His family was allowed to retrieve his body and take it to a local mosque, where it was washed publicly.

We are at our dinner party roughly two weeks after the imam died. Now someone else is sick. The nurse who treated the imam. He dies. At the last minute, the hospital puts the nurse into isolation, sensing – or knowing already – that this was a case of Ebola.

At this point, you can hit the panic button.

In order to beat Ebola, you need to be proactive. You need to anticipate and respond. Quickly. That did not happen in the case of this imam. In fact, just about everything that could have gone wrong, did.

So why were there only 7 cases of Ebola after this debacle? And how were there no cases of Ebola after the 2-year-old girl traveled through the country and ended up in a hospital that may not have taken all the proper precautions while treating her?

Of course, there is no clean answer here, but there are a few things to consider:

Did Malian health officials simply hit it out of the park? Mali’s government intervened rapidly after the case of the 2-year-old girl, even chasing down and disinfecting the bus that the girl took to Kayes. The response was not as swift in the case of the imam, but they did seem to kick into gear after a couple of days.

But the efforts of health officials are only one part of this story. The sick girl was in close contact with her grandmother, and possibly others, on her journey through Mali. According to the WHO, the girl was bleeding from her nose during the trip. When she arrived in Kayes, she was not initially suspected as an Ebola case. The imam went undiagnosed even after his death, and his body was taken and washed without precaution (dead bodies carry the maximum payload of the Ebola virus, and they are considered to be extremely infectious). In both cases, transmission was likely before the government was even aware of what was happening.

Did Mali simply get lucky? That seems unlikely given the fact that there were two separate introductions of Ebola. Both fizzled, and in the case of the second, the circumstances were ripe for a much higher level of transmission.

We do know that Ebola is a fragile virus. It is transmitted through direct contact with bodily fluids, and casual contact with someone who is sick is unlikely to lead to infection. The majority of cases in the affected countries (Sierra Leone, Guinea, Liberia) are health workers, family members acting as health workers, and anyone coming in contact with corpses, whether it’s burial teams or funeral guests.

Despite the fragility of the virus, the outcome of Mali’s two brushes with Ebola is still astonishing. So let’s look at another possibility: Mali has a climate (at least at this time of year) that is not hospitable to the Ebola virus.

You may have read that the Ebola virus can survive for up to 50 days on surfaces. This bit of news made waves when cases started appearing in the western world, inducing a societal panic attack. But this information is misleading.

First of all, this information comes from lab findings. There hasn’t been any research on the Ebola Virus surviving on surfaces outside of a lab. We simply don’t know how a variety of environmental factors could alter the findings. Secondly, the lab research is conflicting. The 50 day study kept the Ebola Virus at 4 degrees Celsius in low light conditions with a relative humidity between 40 and 50 percent. In other studies, the virus was only able to survive for several hours (still in low light and with a humidity exceeding 30%)

At this time of year, Mali’s relative humidity can drop below 20%. While it is getting cooler now, temperatures were quite high following the Clinique Pasteur debacle (Mali has something of a mini hot season from October into November). It’s widely accepted that hot, dry air is not good for viruses of this nature, and Ebola may be even less stable as a virus than other viral hemorrhagic fevers, such as Lassa Fever.

The climate story could very well be a piece of the puzzle. We may never know for sure. We do know that the areas where Ebola has exploded are some of the most humid in all of West Africa. Northern Guinea, which has a climate similar to that of southern Mali has not seen a high caseload while the tropical forest areas of the country have seen significant proliferation of the virus.

Of course, we can’t extract too much information from any one piece of evidence here. What are some other possibilities? Some have suggested that Malians, being majority Muslim, have better hygiene practices. As an explanation for why Ebola did not take off, this seems a bit thin given some of the circumstances. Who knows, maybe it was a factor. What’s left? Divine intervention?

I never thought Ebola was going to explode in Mali. The disease took off in the affected countries because it was allowed to fester. The response was slow and inadequate. Despite Mali’s delayed reaction to the second case, they got on the horse quicker than Guinea, Sierra Leone or Liberia, and they also had immediate help from organizations like the WHO and the CDC. But I didn’t think Mali would get out of this mess with a number of total cases in the single digits. Did anyone else?

Feel free to chime in with any evidence/research/educated guesses as to why this happened. This post is obviously not conclusive by any means.