How Ebola virus came to be wide-spread in West Africa

Presenter: Neal
Guest: Dr. Mardia Stone
Guest Bio:
Dr. Mardia Stone is an International Medical and Public Health Expert. Currently, she is Senior Advisor to the Chester M. Pierce, MD, Division of Global Psychiatry at Massachusetts General Hospital (MGH) /Harvard Medical School and Senior Advisor to the Liberia Center of Excellence in Mental Health and Psychiatry, working extensively on mental health issues, coordinating mental health research and training activities for MGH Psychiatry residents in Liberia.

Segment Overview: Dr. Mardia Stone discusses how the Ebola Virus came to be wide-spread in West Africa and the potential cultural implications of the current outbreak.


HPR – Health Professional Radio

Neal: Hello you’re listening to Health Professional Radio. I’m your host Neal Howard, thank you so much for being here. In light of the recent developments with the Ebola virus, the outbreak in West Africa – now a serious issue in the United States, Spain – stories of Ebola showing up in many many places. Our guest in studio today is Dr. Mardia Stone. She’s an International medical and public health expert. Currently, she’s a senior adviser at the Chester M Pierce Division of Global Psychiatry at Massachusetts General and Harvard Medical School. And most recently this past August, she traveled to Liberia and served as a Senior Adviser to the Incident Manager, Liberia’s response to the Ebola Epidemic. She’s an integral player in deciding where treatment centers for the virus will be built and many other aspects a well. How are you doing today Dr. Stone?

Dr Mardia Stone: I’m doing fine, thank you. How are you?

N: I’m doing well. I’m really glad that you allowed us some of your time. You just returned from Liberia, could you tell me what it was that you saw upon arriving? As far as the Ebola outbreak and the some of your thoughts as to how things can be handled going forward?

S: Well, what I saw in Liberia was people that were terrified and very very confused about what Ebola is. And you know, people just did not know what to expect – who had it, who didn’t have it, who was in their list – because nobody knew and so there was this panic everywhere. Liberians, the people who like to touch each other, the message that was being disseminated was “No touching. No hugging. No kissing. No coming in to close proximity to the other. No hand shaking.” and this is really a change in the culture and the lifestyle for the Liberian people. But what I saw also was a lot of people who did not have access to treatment, who did not have access to the supportive care that is required if you have Ebola. And there was only one treatment center, one Ebola treatment unit in Monrovia, and it went from having a capacity of twenty beds to forty beds to sixty beds to one hundred beds and at the time that I left, they had two hundred beds developed in that facility. It was just a very confusing situation. The coordination was not so effective. Everybody was doing their own thing and basically the structure that we set in place, the Incident Management System, did not occur until the middle of August. So right up until then, you had all of these political task force and all of the political leanings as a whole being in control and we had a lot of egos at play. So instead of focusing on the response, you had a lot of political interventions as supposed to focusing on the actual technical interventions that needed to be put in place. So we were able to establish the Incident Management System in August and it’s working. It seems to be working well now but still with a lot of the political manipulation.

N: You know it’s interesting that you mentioned the political aspect about the response to this outbreak. We hear a lot in the media, on the talk shows, the Sunday morning shows about the politics involved. As you said, “Who is going to take charge? Who is going to do what? Who’s going to be the boss?” as it were in responding to this outbreak. With elections coming up, that’s a very important thing here in the United States especially with our current president, being our president that is deploying our troops in order to aid in this response in Liberia. Now I understand that previously, Ebola outbreaks would occur in very remote areas. Entire villages would be devastated and then you might not hear about it for several months, maybe a year or so, and then would break out to some place that’s totally different.  What are your thoughts on how, after since 1976, all of these outbreaks being remote and localized, it is now spread to major cities in West Africa and obviously to the United States and other places. How do you think that that occurred after so many years of being remote and localized?

S: Well, when Ebola was first diagnosed in 1976, it usually occurred in remote forest areas that was sparsely populated where people lived in villages and in towns and people lived amongst animals. But what has happened in West Africa is that it has been introduced into the rural areas. The migration of people into urban centers caused the transmission to occur in Monrovia, in Liberia in particular, and also in Sierra Leon and Guinea. So the migration of people from the rural communities into urban centers and also the intercommunity migration among these people is one of the reasons that epidemic has spread. For example in Liberia, you have a population about 4.8 million people and in the metropolitan area known as Monrovia, you have about 50% of the population. So you know, when you have this densely populated urban area and you have migration of people from the rural communities where Ebola actually originated, you know, that is a recipe for disaster and that is what happened in Liberia.

N: Now you did mention a change in the culture as it were due to some of these, I don’t want to call them mandates, but I suppose safety and health suggestions as they apply to hugging, kissing, and closed contact with someone who is infected. Before this outbreak, did the Government or any officials either here or in West Africa, addressed the migration as a possible precursor to the Ebola outbreak and do you think that citizens would have adhered to the non-migration suggestion had it been posted to them?

S: Those people did not adhere and I don’t think they would have adhered in the very beginning because in April, in Liberia there were only five reported cases of Ebola so people really weren’t thinking that it was going to spread at the level that it has in Liberia. And so, you know, even though the government has urged to seal the borders, they were being advised by the minister of health, the WHO, “Well you don’t have to seal the borders. It’s going to be localized in the rural area.” Well that’s not what happened because the spread of Ebola into Liberia occurred on the Liberian-Guinea border where an individual left Guinea who had family members in Liberia and was ill. She actually came in to Liberia to be cared for by her sister and this individual died. The sister then decided to leave the rural area in Lofa County and come in to Monrovia to seek care. So on her way, she took a taxi with five or six other people and she became ill in the taxi – vomiting and sweating profusely – and so the taxi driver decided not to bring her all the way into Monrovia. So he stopped on the way and there she was, you know, taken out of the taxi, spent the night in somebody’s house and in the morning was taken to the hospital where she was diagnosed with Ebola. The government at that time, the Minister of Public Health, did not isolate these people. They did not quarantine these people and so they did not know who was in the taxi, who had been exposed and hence the dissemination of these individuals who have been directly exposed to the body fluids – the vomits of this individual – into Monrovia. And that was the beginning of the spread into this urban environment.

N: So we got this exponential spreading of Ebola which there was no way that anyone could have known that this woman was sick with the Ebola Virus but each of the people that were in the taxi, they’ve got contact with others – the taxi driver and those people have contacted with the others. It’s horrifying to think of how fast the virus spreads with 1.4 million people estimated to be infected by just the end of this year. And I think there’s a, what, eight thousand or so reports now?

S: Yes. There’s about eight thousand reported cases and that is an underestimation because a lot of people are still hiding – people that are sick – because they don’t want to be stigmatized. And so people in rural areas are still burying the dead even though they have been told not to handle dead bodies because Ebola in dead bodies are equally infectious. And you have about 70 to 80% of all of the dead bodies that have been tested for Ebola, have tested positive. So you know, you have to assume that until proven otherwise, anybody who dies in Liberia at this point is dying of Ebola. But the people have not been really listening to the public health messages. They are still doing it and in traditional societies, there is ritual for preparing the dead for burial. You know, they wash the body in a certain kind of water and in some societies, they wash their faces in this water after the dead has been washed. In other places, they wash the spouses of these people in this water after the dead has been washed. And that is a definite source of transmission. So you have an entire family, you know, there was a family of seven people who died within a matter of ten days of each other because they were all exposed to a dead body and had attended a funeral. So this is why the spread of Ebola is rapidly increasing in Liberia because people are still adhering to the cultural practices that are not in their best interest at this point in time. The other thing is the contact, for example, there is the contact tracing. We are making the assumption that for every person who has Ebola, they have at least eight to ten contacts and each contact that comes into direct contact with body fluids with an Ebola infected person has to be followed for the 21-day incubation period so that if they, at any point along that spectrum of twenty one days, begin to manifest symptoms, they will be immediately removed from the environment and taken to a treatment center and that is what the Guineans have done. They have a very effective contact tracing system. So effective that when one of their contacts who had had a family member that died of Ebola left Guinea went to the Senegal, it was the government of Guinea that notified the Senegal authority that this individual have left Guinea into the Senegal. That system does not exist to that degree in Liberia. That system is in place but not as effective as the one that is being conducted to the Guinea.

N: You’ve been listening to Health Professional Radio. I’m your host, Neal Howard. We’ve been in studio today with Dr. Mardia Stone and she served as Senior Adviser to the Incident Manager in the Liberia’s response to the Ebola Epidemic. And we’ve been here talking about some of the ways that the virus is spreading and has been spreading throughout West Africa and now in other places around the world. And also talking about some of the cultural changes that are taking place and how these changes will more than likely manifest in the future. It’s been great having you here with us today Dr. Stone.

S: Thank you. I’m glad to be here.

N: Thank you. Audio of this program are available at and also at and you can subscribe to our podcast on iTunes.

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