The recent explosion of Ebola virus cases in a Ugandan rural community began when defiant residents exhumed a body at night, undoing the work of a safe burial team to give the deceased man a proper Islamic funeral.
Within days, at least 23 of the mourners had contracted Ebola and three were dead, prompting Uganda’s health minister to say she hoped the farming community members in the district of Kassanda had learnt their lesson.
But it seems not everyone had.
In a recent community discussion of the challenges health teams face in combating the current outbreak of a strain of Ebola with no proven vaccine, the district’s Ebola incident commander cited pockets of resistance to health measures.
Another official spoke of people who hide in the shrines of traditional healers — who are temporarily banned from working amid the outbreak — and another complained about youths unhappy with restrictions on movement who throw stones at patrol vehicles.
Ebola, which can sometimes manifest as a hemorrhagic fever, arrived here from Uganda’s neighbouring district of Mubende in October as patients crossed valleys and hills to seek treatment. Others didn’t even know they were infected. The early symptoms — including fever, fatigue and muscle pain — can often be mistaken for those of malaria or measles. But failing to isolate infectious patients can have fatal consequences.
When Ebola patients or their contacts are highly mobile, it’s harder to trace them, and new clusters can emerge. At least two people sick with Ebola travelled 150 kilometres (93) miles from this central Ugandan region to Kampala, the capital, where authorities have voiced serious concern after 15 people there — including six schoolchildren — were infected.
Ebola has infected 130 people and killed 43 in this East African country of 45 million since Sept. 20, when the outbreak was confirmed in Mubende days after local officials first noted a “strange illness.” Official figures don’t include those who died with probable Ebola before the outbreak was confirmed.
There are at least 40 active Ebola cases in Uganda, which has had multiple outbreaks in the past. One in 2000 killed more than 200 people.
Ebola spreads through contact with the bodily fluids of an infected person or contaminated materials. During the current outbreak, the World Health Organization has said the fatality rate is nearly 30%.
Last week, the U.N. health agency revised its formal risk assessment, saying the risk to Uganda had been raised to “very high” and the risk of regional spillover was “high.” Scientists suspect that bats are the natural reservoir of Ebola and say outbreaks are often triggered when people come into contact with infected wildlife, including bats, monkeys or antelopes.
Ugandan health officials say most Ebola contacts have been documented by tracers, hoping to reassure people who are worried that further spread of the disease could cause a nationwide lockdown. The Africa Centers for Disease Control and Prevention says the outbreak is under control because of the contact tracers’ efficient work.
But without effective vaccines or medicines, unless everyone cooperates, an Ebola outbreak can be hard to end. This is especially so in a remote community with high levels of illiteracy, where some still link Ebola to witchcraft and choose to address it at home rather than call an ambulance.
Ugandan health officials have achieved “a tenuous degree of control” in the outbreak, said Dr. Atul Gawande, a U.S. official responsible for global health at USAID. Just a few errant individuals can cause the outbreak to change rapidly, he said during a visit to Kassanda Tuesday. Scientists do not consider outbreaks to be over until 42 days — twice the maximum incubation period — have passed without new cases detected.
Speaking to the community, Health Minister Jane Ruth Aceng warned that if contacts continue to run away, “there will be an explosion where they run.” She sometimes said villagers “are like children. You tell them, ‘Don’t touch the fire.’ They touch it.”
On Wednesday, the national Ebola incident commander, Dr Henry Kyobe Bosa, said the outbreak “is entering a phase of potentially sporadic cases” as contacts keep running, as was recently seen in Masaka, along the busy highway to western Uganda.
Some residents of Kassanda and Mubende said movement restrictions in place since mid-October seem worse than Ebola itself. Traditional healers complained they had no income. A food vendor who waits on passenger buses said he lost business. Others said even food is hard to come by.
“It has affected us too much because we don’t have customers to buy our booze. We lock ourselves inside at 7 (p,m.) exactly,” said Miria Twijukye, bitter that after two days, she was still waiting to get her package of government-supplied food rations. “We are suffering so much.”
Even if the measures are necessary, “we need food,” she said, drawing cheers from others in a crowd waiting for free food in Mubende town.
Some in Mubende are concerned about the risk of new contamination from neighbouring Kassanda amid the reports of community resistance.
“This disease escalated from here, and it went to the neighbouring district. And today, I want to report that Kassanda has very many numbers,” said Rosemary Byabasaija, who heads Mubende’s Ebola task force.
In a sign of the shifting epicentre of the outbreak, most of the 24 Ebola patients admitted at Mubende’s regional referral hospital are from Kassanda. Only three are Mubende residents.
“That’s a big problem,” said Byabasaija, talking about the jump in cases from Kassanda after the infected body was exhumed. “I want to appeal to religious … and cultural leaders that this is not the time to go by our (normal) rules and procedures because Ebola kills.”
She spoke worriedly of a trail that some people are following to dodge restrictions, creating unwanted traffic from Kassanda that could hurt efforts to eliminate active cases in Mubende.
“For us, we had fought our war, and we are succeeding,” she said, “but now we are getting challenges (from) people who are coming from Kassanda.”
