Poop Happens: A Key Reason Ebola Never Took Off in the United States

When people ask me what I do, I have become accustomed to keeping it vague, "foreign policy." And if they push, I'll add, "I advise Congress on global health issues." Upon reading their blank expressions, I usually follow that up with, "like HIV/AIDS." And then the light bulb goes off. "Oh, that's cool." They add.

My family, though they deign interest, can tolerate discussions about global health and development issues for about five minutes before their eyes begin to glaze. Ebola changed everything. All of a sudden my friends and family were quite interested in my work. During the peak of the epidemic, I received nightly calls that went something like this, "I know the news usually hypes everything up, but I'm starting to get nervous about this Ebola thing. Should I be?" My usual curt response would  be, "No. We have running water and toilets and a functional health system."

I must admit. After taking calls on Ebola all day, I didn't have the patience off hours to offer the same amount of detail I provided congressional staff. It never failed though, I'd feel bad because there was usually a pause after my quick response and so I'd continue, "Ebola is transmitted through contact with bodily fluids of an infected person or animal. Think about it. When you're sick and you have diarrhea, what do you do?" The caller would usually respond, "What do you mean what do I do?" I'd retort, "I mean where would you go to poop?" "To the bathroom of course," was always the answer. "Exactly. If someone you knew was really sick. Let's say they were vomiting and had a high fever. What would you do? Would you try to care for them yourself?" I'd always receive an emphatic "No!" followed by, "I'd take them to the doctor." "And if they threw up on you while you were helping them to the car, what would you do?" "I'd wash up."

"And that's why you don't have to worry about Ebola. If someone has diarrhea, they'll poop in the toilet. If they're vomiting, they'll throw up in the toilet and if their condition does not improve, they'll go to see a doctor. The doctor will likely be equipped with basic protective equipment and will not likely contract the virus. For all those reasons, you do not have to worry about Ebola." That usually calmed the nervous friend or family member, until of course Texas experienced a couple of cases. After Texas, my conversations were about 10 minutes longer and I sensed a lingering skepticism. After which I'd usually add, "Now if you want me to freak you out, I can freak you out. We can talk about multi-drug resistant tuberculosis, or the spread of vector-borne diseases like dengue for which we have no treatment, or how about the declining bee population?" That would usually end the phone call.

In my mind, the Ebola outbreak resolved any debates about whether water, sanitation, and hygiene (WASH) is a "health" issue. I understand that water and sanitation services are not managed and run my Health Ministries. That should not stop us global health folks from embracing our WASH family. Quite frankly, I think it's futile to try to disentangle health and WASH.

In the early phase of the Ebola outbreak, CDC conducted a survey of health clinics in Liberia. The agency found "basic materials for standard infection control practices such as gloves, soap, and water often were inadequate." In one hospital, for example, the isolation area for Ebola patients lacked toilets and running water. CDC officials also witnessed health workers sharing and reusing gloves intended for single use, due to supply shortages. It's no wonder that roughly 25% of Ebola cases were among health workers at that time. It also should not come to a shock that people became afraid of attending health clinics when they became ill, and rightfully so. Due to poor infection control practices, one could actually contract Ebola at a health center.

Attempting to explain to staffers day in and day out how these issues interlinked was exhausting. Receiving push back from my global health colleagues about whether WASH should be part of health system strengthening efforts was confounding. The World Health Organization conducted a study in 66,101 health facilities in 54 low- and middle-income countries and found that many clinics lacked adequate supply of clean water and sanitation, like those in Liberia. Among the surveyed clinics, 38% did not have any water source, 19% lacked improved sanitation facilities and 35% were without soap and water for hand washing. 

Inadequate access to WASH negatively impacts health outside of clinics as well. It causes more than 0.8 million deaths annually and contributes to undernutrition and stunting. The Ebola outbreak has raised awareness about the threat weak health systems pose to health security and the international community is working towards identifying strategies for bolstering weak health systems. In my view, WASH should be part of these discussions. The President of Liberia thinks so too. What are your views?