I’m an Ebola expert – it is out of control, and worse is to come

As the number of confirmed cases of Ebola in the Democratic Republic of Congo climbed past 1,000, there is few people looking at these horrific numbers with as much knowledge and seriousness as Simon Mardel. Over the past three decades, the 69-year-old NHS consultant in emergency medicine has been at the forefront of the world’s worst Ebola outbreaks.

While nowadays healthcare staff are equipped with layers of stifling PPE that limit their time on the isolation wards to a maximum of 40 minutes, when Dr Mardel first became involved in the 2000 outbreak in Gulu, northern Uganda, (at the time the worst in history) he and colleagues wore just surgical masks, apron, gloves and eye protection and worked 12-hour shifts at a time.

That close and prolonged proximity to patients has afforded him a rare clinical understanding of Ebola and the cruelty of a disease which poses the gravest risk above all to those who care for the dying.

In the 2000 outbreak, for example, more than 20 of Dr Mardel’s colleagues died, the last of whom was Dr Matthew Lukwiya, the esteemed medical superintendent of the hospital where he worked. After he started feeling unwell, Dr Mardel gave him a medical examination during which both men realised he had developed telltale oedemas (swelling) of the ankles, which they had learned earlier was an early indicator of severe infection.

As the disease takes hold, patients suffer extreme vomiting and diarrhoea, which leaves them severely dehydrated and dangerously weak. The virus triggers waves of inflammation throughout the body which can cause blood vessels to leak and blood pressure to plummet; vital organs including the liver and kidneys then begin to fail. In some cases, internal bleeding compounds the damage, which is when you get the horrific images of Ebola victims bleeding from their eyes. But ultimately it is the combination of dehydration, circulatory collapse and multi-organ failure that prove fatal.

A person who has died from Ebola remains highly infectious as the virus can persist in bodily fluids after death, which is why specially trained teams use strict protective measures in the handling and burial of Ebola victims

Dr Mardel ended up caring for his friend in a makeshift intensive care unit he helped build, before his patient eventually succumbed to the virus. “The hardest working cleaners, nurses and doctors, they are the ones who are at the highest risk,” he says. “It takes out the best people in healthcare in these environments.”

Over recent months, these former colleagues and friends have been foremost in Simon Mardel’s mind as the current outbreak in the Democratic Republic of Congo (DRC) spirals out of control. The latest update from Congo’s Ministry of Health shows that as of Sunday, 2,473 cases have been recorded in the latest outbreak, and 999 people have died, including numerous healthcare workers and three Congolese Red Cross volunteers. The World Health Organisation (WHO) has declared it a public health emergency of “international concern”.

Months ago, aid agencies raised concerns that there could be far more undetected cases, as the outbreak may have started in January and spread unchecked for several months before being officially confirmed by the Congolese Ministry of Health on 15 May. The current outbreak, for example, crossed over to neighbouring Uganda a month ago, thankfully, the country’s last confirmed Ebola patient was discharged from care on Thursday after testing negative for the virus twice.

A humanitarian worker is being observed in a London hospital following a potential exposure to Ebola in the DRC, health officials have said.

Possible cases were also detected in Brazil and Italy before being ruled out by health authorities in both countries. The situation is also exacerbated by attacks on clinics fuelled by misinformation shared on social media which has also led to people avoiding hospitals and other healthcare facilities.

With the latest outbreak being caused by the rare Bundibugyo strain of the virus for which there is no vaccine, there are fears it could potentially surpass the 2014-2015 outbreak in west Africa, when more than 11,000 people died. Dr Mardel, who during that outbreak was working as clinical case coordinator for the WHO in Sierra Leone, describes observing this latest tragedy unfold as like “watching a train crash in slow motion”.

Of particular concern, he says, is the lack of understanding about the true scale of the current outbreak and how far and how fast it is spreading through undetected cases. “I think it’s safe to say it could be unprecedented,” he says. “The words an epidemiologist should never want to hear are ‘unrecognised chains of transmission’.”

Dr Mardel’s involvement in the current outbreak is at a state of remove. He retired from his full-time NHS role a month ago and now works as a locum consultant in emergency medicine across the north of England. But even monitoring the situation in central Africa from his home in Cumbria, he has seen enough parallels with the mistakes of previous outbreaks – not least around failing surveillance of cases and poor infection control — to fear that this could be the worst yet. “I’m worried that a lot of the lessons haven’t been learned,” he says.

This year marks a grim anniversary of sorts: 50 years ago the Ebola virus was first detected in then Zaire in 1976 and there have been 17 outbreaks in DRC alone since. Since the turn of the century, outbreaks have gained in speed and ferocity, spreading rapidly across borders. Dr Mardel believes it is “only a matter of time” before the disease spreads out of Africa into countries and healthcare systems that are entirely unprepared to contain its spread.

His biggest immediate fear is that the current outbreak will reach Nigeria, Africa’s most populous country, with 250 million citizens. The virus flared up there in the 2014 outbreak, and Dr Mardel was involved in its containment. He says that only an astonishing amount of good fortune prevented the disease from fully taking hold, and warns it will not be the same a second time around.

“The potential to amplify in hospitals is phenomenal,” he says. “You could get one in and potentially 20 or 30 or even 50 coming out.”

One of the important and largely unexplored drivers of Ebola outbreaks is the link with illegal gold mining. Early in his career, Simon Mardel spent several months alone in DRC investigating links between marburg disease (a viral haemorrhagic fever near identical to Ebola which is also harboured in bats) and an illegal gold mine.

He describes recording hellish scenes from the deep shaft mine of more than 1,000 men working for days underground among putrefying corpses killed in rockfalls and drinking water streaming down the walls of caves streaked with layers of bat excrement. The 2014 Ebola outbreak has also been traced to a deep-mining area in Guinea, and the latest outbreak started in the Ituri province of DRC and in particular the gold-mining towns of Mongbwalu and, across the Ugandan border, Rwampara.

Years of experience have taught Dr Mardel that speed is the most crucial ally in providing treatment to people who have contracted the disease. “All the data shows that by five days, and by some markers three days, the die is cast and you can start to see who is going to die,” he says.

Speed is equally important in regard to tracking the virus. If you have an outbreak of 100 cases, he argues, then that is already 2,000 or so contacts who need to be traced by epidemiological surveillance teams. As cases continue to appear far away from Ituri province, Dr Mardel fears this outbreak may already be out of control.

“They are lagging behind,” he says, “and if that is the case, even though DRC has a lot of experience with Ebola, then I think we are in trouble.”

While he admits that the link between gold mining and the start of an outbreak remains something of a hunch, what is undisputed is that they are communities which provide the conditions for rapid spread among clusters of relatively affluent young male workers, prostitutes and private healthcare facilities.

On both personal and professional levels he has seen at first hand the worst that Ebola can do. But left to ravage an entire continent, and possibly beyond, is a nightmare scenario increasingly, he believes, within the realms of possibility.

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