Bringing Ebola Home (part 1 of 2)

Eric Lis

For the past few weeks, the Ebola virus has arguably been one of the biggest news stories in the entire world. This has been a very mixed thing. It's been wonderful, because Ebola is a major world health issue and a horrific malady which we actually have the power to do a great deal about. On the other hand, it's also been sort of miserable, because a certain percentage of the media coverage has been scare-mongering, misinformation, and general inaccuracy. I'm not saying that there's anything wrong with scare-mongering and misinformation, of course, but there's a time and a place for it, and I have this odd belief that the news should give us useful information as opposed to fear and confusion.

All that being said, here's some information that'll allow you to spread fear and confusion among your players.

When I saw how long my first draft of this column was getting, I decided to split it into two parts, for the sake of your sanity. This week, you get a superficial summary of the actual medical information, which will help you understand a bit about what Ebola is (and what it isn't) and also give you enough information to describe it in your campaign. Come back next week for game mechanics and some ways specifically to integrate an Ebola-like plague into your world.

First a brief disclaimer. Any time that you use a disease in your game, you risk upsetting or offending a player. As a storyteller, your job is to understand how your players will react to the things you put in your story. Because Ebola is a very real world problem at the moment, it has the potential to be emotionally-charged. Before you use it, consider whether any of your players might be worrying about relatives in an affected region or otherwise be sensitive to the material. It's possible that your goal is to upset someone, but that's not usually the case.

Ebola is a viral illness from a family of bugs known as the filoviruses, which also includes the deadly but less marketable Marburg virus. Ebola has been further subdivided into several different species, including Zaire, Sudan, Ivory Coast, Bundibugyo, and Reston, each of which has a different degree of virulence and lethality. The current outbreak in the news seems to be the Zaire species, which is unfortunately the deadliest one according to most statistics.

Contrary to the impression that many people have, Ebola is actually not terribly easy to spread. You cannot easily contract Ebola from the other side of a room, and in fact, the CDC and the WHO define three feet as the "low-risk" distance from someone known to have Ebola. It's even considered fairly safe to shake hands with an infected person, although you should then wash your hands before eating or rubbing your eyes. Spread of the virus generally requires direct fluid transfer, which might include handling an animal's blood or organs, or eating infected tissue. For example, one of the first known outbreaks of filovirus is believed to have been in Europe, among factory workers who butchered and cut up a sample of Ugandan monkeys. If the workers had not literally been up to their wrists in monkey guts, they might never have contracted the virus. As it stands, this case is the only time there has ever been a meaningful outbreak of filovirus outside of sub-Saharan Africa, although African outbreaks have been becoming more and more common in the past twenty years. Unlike very delicate viruses like HIV, however, Ebola doesn't necessarily require open wounds or immediate and super-close contact. While I couldn't find data on precisely how long Ebola can live in the open air (probably several days, but we don't have good data), we know that apes can contract the virus through virus-laden droplets coming in contact with the eyes or the mouth. There's some suspicion that Ebola can be transmitted through certain African funeral rites, wherein the body of the deceased is ritually hand-washed by family members; this can result in people coming in contact with still-active bodily fluids. Most of the body's major fluids -- blood, stool, urine, sexual fluids, and even breast milk -- can contain living virus, some of them after the virus has been eradicated from the rest of the body. Infection by the respiratory route -- by a cough or sneeze, for example -- seems to be possible, but astoundingly rare; it's been shown in animals, but in humans it's only ever been documented in healthcare workers who have had intense, prolonged, close contact with the sick person. It's unclear whether sweat is infectious, although the data seems to lean towards "no." Numerous cases have been linked to eating dead animals; Ebola virus seems to be killed through proper cooking, but raw or rare meat poses a danger. As near as we know, people do not become infectious until they're actively symptomatic; there is no evidence that someone can be symptom-free and contagious, and simple hand-washing seems to be the single most effective preventative measure we have, and this is why much of the panic in the West seems to be relatively unfounded.

One of the big mysteries about Ebola is where it hides. Many viruses and bacteria have "reservoirs," species which carry the infectious agent but aren't themselves harmed by it. This mechanism allows the agent to hide for some time and then re-emerge at a later date, long after we believe it's been eliminated from a region. Thus far, and despite a great deal of research, we haven't identified Ebola's reservoir. The most popular theory is that it's in some form of some small animal which is eaten by both humans and non-human primates, most probably bats.

As for Ebola's effects on the body, they're rapid and widespread. We don't know much about how Ebola actually affects humans, because it's difficult and ethically questionable to study and dissect sick humans; most of what we know comes from observing infected animals. Symptoms of Ebola typically manifest within days of infection. The earliest symptoms are mild and non-specific: fever, sore throat, and headache. A few days later, symptoms worsen, evolving into severe gastrointestinal distress with vomiting and diarrhea. Severe dehydration, as well as the virus' own toxic effect, causes damage to the kidneys and liver. The viruses destroys or suppresses key immune cells and tissues, reducing the ability to fight back. Destruction of immune cells floods the body with an overdose of inflammatory chemicals, and the body's own dysregulated immune system causes many of the subsequent dangerous symptoms: drop in blood pressure, confusion, pain, high fever, and towards the end, uncontrolled bleeding. If the person is going to survive, symptoms usually improve after about six days or so. The body's immune system gets itself back on track and starts producing antibodies against the virus, getting it under control. Healing is slow, and even as people regain their strength, skin and hair often continue to slough off as the body's tissues rebuild.

Because it's a virus, as opposed to a bacterium or a parasite, we don't have a lot of very good medications with which to treat Ebola. The best medical treatment is currently limited mostly to supportive measures: hydration and electrolyte replacement, maintenance of blood pressure, and nutritional support. A number of experimental therapies are currently being tested, including antiviral medications, designer antibodies and blood transfusion from people who fought off the illness. Preventing transmission is considered to be far more effective than treating.

In Africa, where resources to provide proper treatment may be lacking, the mortality rate of Ebola is thought to be as high as 70% during the current outbreak, which is actually down from the rate ten years ago when it was closer to 90%. According to my personal favourite medical information website, UpToDate, as of October 14th, in West Africa, there had been 9216 confirmed cases of Ebola, of whom 4555 had died. Of the 423 health care workers infected, a little more than half have died. These numbers are almost certainly under-estimations.

More than four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on October 18, 2014. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system