When Dr. Olivet Buck became the fourth Sierra Leone doctor to die from Ebola after she was denied evacuation, the third American healthcare worker to contract Ebola in West Africa was well on the way to recovery back in Omaha, Nebraska.
For many African healthcare workers, who form the bulk of the aid team, a lack of funding has prevented their medical evacuations to Europe or the U.S., where treatment and facilities are more robust. For Western workers, though, systems are already in place for those who become infected with Ebola. And the procedures are, comparatively, fairy tales. Patients are whisked away in futuristic medical evacuation planes. Doctors rush to approve the use of experimental drugs. They will live to tell their story, or so it has been reassured in the U.S. after the nation’s first confirmed Ebola patient.
But most Ebola-infected healthcare workers will not be as lucky as Dr. Rick Sacra, or his fellow American Ebola survivors, Nancy Writebol and Dr. Kent Brantly. While one would think that healthcare workers, of all people, would be less likely to succumb to Ebola if they contracted the virus, the fatality rate of Ebola-infected healthcare workers is a stunning 57%, according to WHO’s most recent data. Even more remarkable is that the overall case fatality rate of the 2014 West Africa Ebola outbreak is 47%, and the two rates appear only to be diverging. (A chi-squared test shows the difference is statistically significant at the 0.05 level, meaning it is unlikely this discrepancy is due to chance.)
WHO spokesman Tarik Jasarevic cautioned that the numbers are not perfect, but said they do illuminate a significant trend: Why are healthcare workers just as easily, if not more easily, falling victim to the virus they’ve set out to defeat?
Dr. Buck’s story, like similar cases, suggests an insufficiency of resources—or what some have alleged to be a “callous lack of compassion”—to care for the African nationals who are the backbone of the Ebola aid force. “[The discrepancy in fatality rates] is a natural occurrence, because healthcare workers are the ones who are dealing with patients infected with Ebola,” WHO spokesman Daniel Epstein said. “We haven’t had good enough facilities in the countries to treat healthcare workers themselves.”
As citizens of Liberia, Sierra Leone or Guinea—the three main Ebola-affected countries—many of these workers are not operating under the shelter of organizations like WHO and Médecins Sans Frontières (MSF). Many locals are also working in poorer clinics that lack ancillary personnel, or proper sanitation practices, isolation units or supplies, all of which are more readily available in clinics established by international agencies.
“An MSF center is sort of like going to the supermarket, and buying a ready-made meal,” said Dr. Daniel Bausch, an infectious disease expert who treated Ebola patients in Sierra Leone this summer. “It comes with everything you need.”
Out of more than 200 total healthcare worker deaths, MSF has lost only a few workers, an MSF coordinator told reporters in Liberia two weeks ago, revealing for the first time the group’s exposure. WHO, which has had at least one worker become infected, has a policy to evacuate its own staff if they become infected with Ebola, Epstein said. But the agency cannot provide the personnel, resources or money to evacuate local workers. “We’re not the emergency evacuation service,” Epstein added. “We barely have enough money to send people out as it is.”
While WHO’s data does not delineate foreign and local healthcare worker infections, Bausch, who is also a frequent WHO consultant, said that only around 10 of the over 300 total worker infections are expatriates. The rest are local African workers. Part of that difference is because there are simply more local workers, said Dr. Susan McLellan, a Tulane professor who treated Ebola patients in Sierra Leone in August, but the other part is the sheer nature of being a WHO staffer: “We specifically were not resource-poor.” And if a WHO doctor were to fall sick, Bausch described an unspoken promise between the agency and its staff: “If I try to recruit you as a healthcare worker to go to Sierra Leone in relatively rough circumstances to treat people with a dangerous disease, it’s hard for me not to say, ‘well, we’re going to take care of you.'”
But between local workers, that same promise of care, while equally sincere, is less dependable. In Kenema, Sierra Leone, where Tulane professor Dr. John Schieffelin arrived under WHO to treat Ebola patients, each worker’s infection was a resounding blow to the local staff’s efforts not only to maintain care for patients, but also for each other.
“When they see one of their colleagues fall ill, it’s not just personally devastating because it’s one of their colleagues. It’s also very unnerving for them because they all took the same precaution,” Schieffelin said. “Sometimes, a lot of the staff may not show up for work for a couple of days because they were emotionally distraught about the situation.”
Bausch recalled similar memories of when he and another doctor put on their protective suits, traveled to a Sierra Leone Ebola ward and discovered that they were the only two staff in a clinic of 60 Ebola patients. There was stool, vomit, blood and even patients on the floor. The nurses had gone on strike to demand better worker healthcare after some had fallen ill with Ebola. “In some places it’s a very negative cycle,” he said. “You have a nurse who gets sick, and the morale and willingness of the rest of the staff to keep working often goes down. Then even fewer people are working in the ward, and it gets more dangerous.”
Of the three main Ebola-affected countries, Sierra Leone has the highest healthcare worker fatality rate of 71%, a figure that has spiked in recent weeks. It is more than twice the country’s overall case fatality rate of 27%. (The difference is extremely statistically significant at the 0.0001 level.)
For comparison, Liberia’s and Guinea’s healthcare worker fatality rates are 51% and 52%, respectively, and they are lower than the countries’ overall fatality rates.
Jasarevic, who recently returned from visiting clinics in Liberia, Sierra Leone and Guinea, denied that there are problems specifically affecting Sierra Leone’s healthcare workers. Bausch and Schieffelin also believe the problems they observed in healthcare worker Ebola infections are not endemic to Sierra Leone. Dr. Susan McLellan, a Tulane professor who treated Ebola patients in Sierra Leone in August, said that it is difficult to compare conditions that are “abysmal” and “so far below what really needs to happen.”
But Sierra Leone has, however, lost the most number of local doctors, with Dr. Buck being the latest, according to several reports. The nation also has a steadily increasing number of new reported Ebola cases each week, unlike Guinea and Liberia, where figures have occasionally flatlined, according to WHO’s latest data. Sierra Leone is also the country where MSF provides the lowest bed capacity, despite being the second hardest-hit country, according to data provided by MSF spokesman Tim Shenk.
Regardless of what McLellan called “a trick of the numbers,” the alarmingly high number of worker fatalities is driving a new treatment strategy that focuses on preserving the most valuable resources: the workers. Epstein said the “priority” of the U.S. troops deployed to West Africa was to establish treatment centers in Liberia, specifically for healthcare workers, and not patients, a project that Jasarevic confirmed has not yet broken significant ground.
“Putting up hospitals specifically for healthcare workers is an inequity of care, but it’s one of the only ways that one can convince people that they will be taken care of if they get sick in as good a manner that can be provided,” said McLellan. “It was my safety first, their care next.”
Still, treatment of ill healthcare workers is generally secondary to preventing their infection, the sources of which are too plenty to count, especially for local workers. TIME reported, for example, that a Liberian ambulance worker was rushing to transport a sick child, who vomited on his suit, and didn’t stop to disinfect himself with a full-body chlorine spray. In another case, Epstein recalled a dispatch from a WHO doctor working in a hospital where 25 of the 28 local nurses were infected with Ebola, due to either poor protection, inadequate sanitation, or even a careless needle stick. McLellan added that local staff were routinely called upon by their families to treat potential cases in their homes, where there isn’t adequate protection.
“There’s generally an assumption [local healthcare workers] get infected in the Ebola wards, but we really don’t know for sure if they’re getting infected in the wards, or out in the community, or while working in other clinics,” Schieffelin said.
While WHO cautions that its data may not be fully representative, several doctors said the healthcare worker fatality rate may mitigate the problem of precisely estimating the overall Ebola fatality rate, which is almost impossible to know. But Ebola in healthcare workers has a stronger documentation. They are trained to spot symptoms and less likely to resist care. They also generally receive treatment alongside their patients in the same clinics that employed them. “[The healthcare worker fatality rate] is more likely to be truly reflective of what’s going on,” Bausch said. “It’s probably a little bit more of a true [overall] case fatality rate.”
And in that case—if patients are actually falling victim to Ebola as fast as healthcare workers—then the Ebola outbreak is even more dire that what’s currently reported. The CDC estimated that there could be 1.4 million Ebola cases by January if there is no significant additional intervention. And some doctors are urging, with warranted selfishness, that this extra help be provided to their own.
“We feel like we owe that to healthcare workers,” Bausch said. “We owe it to them for taking on these dangerous jobs.”