Ebola outbreak projected to surge as response repeats mistakes of Wuhan

Uganda’s Ebola outbreak is expected to become one of the deadliest within six months, according to leaked government projections which point to 1,200 cases and 500 fatalities by late April.

The modelling, drawn up by the Ugandan Ministry of Health, estimates that 250 people will die by January in the spiralling epidemic, rising to 499 by the spring.

It comes amid signs that the mistakes of secrecy and prevarication which characterised the early days of the coronavirus pandemic in Wuhan are being repeated in Uganda.

At least 136 cases and 53 deaths have been confirmed since the hemorrhagic fever was detected in mid September. The disease has spread across eight districts, including the capital Kampala – an international hub which is home to roughly two million people. 

Insiders say a “toxic” atmosphere has developed. Relations between the authoritarian government and international agencies on the ground are tense, while many local officials have been alienated and feel unable to raise issues or challenge their superiors.

Supply shortages are also significant. Health workers have complained of inadequate PPE, while limited food for those in quarantine means some patients and their contacts have escaped isolation – spreading the virus.

“Initially the impression was that this was small and under control and would burn out,” one source close to the response told the Telegraph. “Now the impression is that this is rapidly getting out of control, or is out of control. And a lot of the steps that could be taken to mitigate and respond are not being taken.” 

The government’s models, shared in a 15 page document dated October 31, were pulled together to inform assumptions about budgets, PPE and staffing requirements – including the size of burial teams and amount of medical equipment needed. 

If the epidemic follows the predicted trajectory it would become Uganda’s worst, surpassing an outbreak in 2000 when 435 infections and 224 fatalities were recorded. The working assumptions suggest that 53 per cent of cases will be adults.

The latest epidemic would also become the third deadliest globally. Between 2014 and 2016, 11,000 people died in the West Africa epidemic, while there were 2,287 fatalities in the Democratic Republic of Congo between 2018 and 2022. 

Recent Ebola outbreaks have been controlled with vaccinations but for the Sudan strain virus impacting Uganda there is no vaccine.

The Telegraph understands that the current projections are not considered to be a worst case scenario, but are “all based on current rates [continuing]... without it (a) getting better or (b) getting worse”. 

Sam Scarpino, co-founder of the analytics group Global.Health, said the model fits with “back of the envelope” calculations, but that the lack of cases in other countries is reason to be optimistic that the number of undetected infections is limited.

Best-case scenario ‘has already passed’

However, sources close to the response in Uganda said they would not be surprised if the death toll swells to 500, as most people infected are currently being diagnosed only after five days of symptoms.

“This is one of the single biggest issues right now in this outbreak [and] means they may have already spread it, and affects their chance of survival,” said one, who asked to remain anonymous for fear of retribution. 

Although the World Health Organization initially stressed that Uganda had the resources to rapidly contain the virus, the agency upped its threat assessment in late October. It warned “the risk can be assessed to be very high at the national level, and high at the regional level”, and expressed concerns that patients are not being found and isolated fast enough. 

“In terms of scenario planning, we have three scenarios,” Abdi Mahamud, acting director of the WHO’s Alert and Response Coordination Department, told journalists last week. “One is the best-case scenario – we’ve already passed that stage.

“The second scenario is a sustained transmission where the outbreak is limited to certain but can also spread. And the last one is the worst-case scenario. So, the government is to attempt every measure possible so that this outbreak can be contained.”

On Saturday, the government extended a three-week lockdown on two districts at heart of the outbreak, curbing travel and closing public places. The education minister added on Tuesday that the school term will be shortened by two weeks to help curb the spread – so far 23 cases have been confirmed in children, including eight deaths.

But on the ground, there are signs that the response has not run smoothly, with serious delays in the crucial early stages of the response. While some issues around supplies have improved in the last few days, The Telegraph has spoken to numerous people involved who have painted a picture of a “chaotic” situation with “weak [political] leadership”.

“It’s incredibly difficult here,” one individual said. “It’s a pretty toxic environment… [while] case numbers have increased significantly and there just aren’t enough healthcare workers to look after them.” 

Doctors and nurses have also complained that PPE has been inaccurate, salary increases haven’t been fully implemented, and that they haven’t been paid in over two months. This pushed medical interns to go on strike on Monday.

At a news conference over the weekend, one intern was in tears. Blessed Kitentera said interns had only been paid every three months, meaning they were unable to cope with the rising cost of living. “A very very hungry intern is very dangerous to the patients”, she said. 

The disease has already taken a heavy toll on healthcare workers – infecting 18 workers and killing seven. 

“We absolutely need to protect and look after first line responders,” warned Dr Charlie Weller, an infectious disease expert at Wellcome. “Without them being present, everything breaks down.”

There is also concern that a lack of coordination within both government and external agencies initially led to shortages of food for Ebola patients and quarantined contacts, with some going hungry due to delays in agreements being signed. 

Rural communities are also wary of the commissioners in charge of Uganda’s regional Ebola task forces, who, as presidential appointees, are frequently viewed as government spies. This has undermined confidence in crucial prevention messaging delivered to small towns and villages. 

Chaos echoes China’s Covid response

It has also made it harder to build the trust needed to encourage people to go to medical centres, rather than traditional healers, when symptoms emerge, and to ensure practices such as safe and dignified burials – which limit spread from dead bodies – are followed. 

Last week, it emerged that 23 people were infected after exhuming an Ebola victim to give the man an Islamic funeral. Three of those who attended have since died. 

Dr Weller, who is not involved in the response on the ground, said that building trust will also be critical for any rollout of the experimental vaccines set to be trialled in Uganda.

Tensions between the government and its international partners are also evident – on several occasions, the health minister Jane Ruth Aceng has publicly chastised donors for channelling money through agencies, rather than giving cash directly to the ministry. 

The UK has not sent funds directly to Uganda, but has instead committed £2.2m to organisations including Unicef, the WHO and the World Food Programme. Similarly the US Ambassador to Uganda, Natalie Brown, cited a report into corruption by the Ugandan government's auditor when asked why America has sent $22.5m indirectly. 

“Funds don’t necessarily make it where they need to go, and that is a very real and serious challenge, and that is also one of the reasons why we work through so many of our other partners instead of just providing direct budgetary support,” she said. 

The chaos has echoes of China’s early Covid response, when local officials feared the repercussions of raising issues with superiors, and there was a crackdown on those who contradicted the official narrative. 

The Telegraph understands that in early October, the Uganda Virus Research Institute, a leading government-run institution with serious expertise on Ebola outbreaks, was cut out of the response because of a feud with the central government – which contributed to delays announcing cases in Kampala.

“In this system, we have so much power concentrated at the top,” said Dr Olive Kobusingye, a Senior Research Fellow at the department of public health at Makerere University in Kampala, who is not directly involved in the Ebola outbreak response. 

If someone takes action and is deemed to be wrong, politically or technically, “the consequences are going to be really nasty for you,” she added. “So what people do – instead of responding and acting promptly – is, they wait for cues… in the meantime, nothing is happening.” 

The Telegraph has contacted the Ugandan Ministry of Health for comment.

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