How Mali conquered Ebola

These signs — which say “Stop the Ebola virus: Wash your hands regularly with soap” are still ubiquitous around Bamako three months after WHO declared Mali Ebola-free.

This blog originally appeared on Global Health TV on April 28, 2015.

BAMAKO, Mali — In the year-old Ebola epidemic, most of the attention has justifiably been focused on Guinea, Liberia and Sierra Leone, where the vast majority of the cases (26,044) and deaths (10,808) have taken place. But what about those countries that have successfully controlled Ebola — Mali, Nigeria, Senegal, Spain, the UK and the US — which account for only 35 cases and 15 deaths? 

I am spending two months in one of those countries and wondered how Mali conquered Ebola. Even though the World Health Organization (WHO) had declared Mali Ebola-free in January, I had barely stepped off my airplane at Bamako–Sénou International Airport on March 14 when I encountered Ebola control: I was scanned for a fever and offered hand sanitizer before entering the airport terminal.

Mali went on high alert after confirming its first case of Ebola in late October of last year, when a 2-year-old girl who had traveled from Guinea to Mali died. The country moved quickly in what the government considered an emergency situation. The child, who was symptomatic upon her arrival in Mali, had traveled extensively in the country using public transportation. Aggressive contact tracing was undertaken but none of the contacts showed symptoms.

It looked like the country had dodged a bullet, with only one death. But then an imam from Guinea was admitted to Bamako’s prestigious Pasteur Clinic with a diagnosis of acute kidney failure, and died on Oct. 27. That case set off a chain of transmission that led to seven additional Ebola cases and five deaths, including a doctor and nurse who had treated the imam. He was buried with full traditional rites, including washing of his highly contagious body, which may have exposed mourners to the virus.

The government put the clinic and the imam’s mosque in full lock down. By Nov. 18, 600 people were being monitored and 90 people were quarantined, including about 20 U.N. peacekeepers who had been treated at the clinic for injuries sustained on duty.

The Ministry of Health launched campaigns with information about how to avoid Ebola in French and several local languages, mostly focused on hand-washing, and established a telephone hotline which eventually received 6,000 calls per day. Calls were analyzed to determine where public messages needed to be tweaked. Some callers reported suspected cases. All such reports were investigated but no further cases were found.

As a result of the information campaigns, some traditional practices were altered. Malians told me they avoided shaking hands and instead greeted people with a wave or by clasping their own hands and bowing. Sometimes they avoided eating from the same dish, which is the norm in Mali and many other countries in Africa, and changed their burial rituals. Some reportedly kept their children from playing with other children.

People started washing their hands more and hand sanitizer became widely available, something that was not previously common in Mali. At some churches, bottles of hand sanitizer appeared at the door and the passing of the peace was discontinued. Even now, in April 2015, billboards promoting hand-washing are ubiquitous around Bamako.

PSI Mali Country Representative Alex Brown believes that hand-washing was overemphasized during the Ebola crisis in Mali. Brown has two main problems with the emphasis on hand-washing.

“First, it doesn’t address the known transmission vectors that account for the vast majority of Ebola cases – like touching dead bodies at funerals, inadequate clothing and protection for care-givers of sick people, transportation of sick and dead people and eating wild animals,” said Brown. “Second, now that the country is Ebola-free, if you were washing your hands to prevent Ebola, you can now stop or neglect hand-washing, right? That’s a bad outcome, because hand-washing is a great thing for a thousand other reasons.”

Several Malians told me that many of the good practices adopted during the crisis have been abandoned now that Ebola is in the past. For example, hand sanitizer has become much less common.

But whatever Mali did, it was enough to eradicate Ebola. On Jan. 18, WHO declared Mali Ebola-free after 42 days with no new cases.  There were several reasons for that: Mali had its own high quality laboratories, which facilitated rapid detection of cases. Contract tracing was rigorous and most contacts were monitored in isolation. The information campaigns communicated prevention measures to people throughout the country in a variety of languages. And Mali learned from Guinea, Liberia and Sierra Leone.

“I think what was different in Mali is that we learned from the other countries and were prepared,” said Bijou Muhura, the Ebola coordinator for the U.S. Agency for International Development in Mali. “There was a team of WHO and CDC (Center for Disease Control) experts in the country when we had the first case. They were here to help with preparedness and that got shifted to actions. The U.S. government team worked very closely with all agencies, and with all other donors and partners including WHO, Médecins Sans Frontières and the UN Mission for Ebola Emergency Response.”