Interview with Dr. Monica Musenero
Dr. Monica Musenero is an epidemiologist and veterinarian who serves as the Senior Program Officer for the African Field Epidemiology Network -- a nongovernmental organization working to build networking capacity among public health organizations on the African continent. Currently, AFENET operates in 15 countries. FRONTLINE/World reporter Serene Fang interviewed Dr. Musenero at their central office in Uganda.
FRONTLINE/World: What are the challenges specific to zoonotic diseases in Uganda?
Dr. Monica Musenero: Zoonotic diseases need to be given more attention in this part of the world. They typically fall into two categories: emerging diseases and endemic diseases. New emerging diseases tend to attract a lot of attention, but the problem is that it usually takes a long time to detect them. When a new disease emerges, it often affects a lot of people before it is confirmed and a response is mounted. So that has been a challenge. In most of the outbreaks we have had -- like Ebola -- we lost a number of health care workers because we hadn't diagnosed it yet.
The second challenge is with endemic diseases that have been around for some time. They often fall in a gap between public health and animal health. For instance, rabies kills quite a number of people in Uganda, but no one is paying serious attention to it. There is a similar situation with diseases like brucellosis and bovine TB.
The challenges, of course, are challenges of resources. The public health systems tend to focus on those few diseases they consider of great public health significance, and then, on the animal health side, they tend to concentrate on those diseases they consider of economic interest. We lack hard data for the ones that fall in between; we can’t quantify the burden. For many of these diseases, we don’t even have accurate diagnostics. So it is really difficult to document or even to tell how much of it is there.
Also, some of the interventions for the control of zoonosis have huge economic implications, and countries have to make the decision, for example, whether to test for disease and possibly slaughter. If you are going to test people’s animals for brucellosis or TB and slaughter the infected ones, you must be able to compensate the owners, which is quite difficult here. So, we’ve tended to live with the diseases, rather than take care of them.
And the other issue has been the gap between the different sectors: The veterinary and the medical professionals are trained separately, and then they each work separately, with very little interaction between them.
Is there a risk of these diseases spreading beyond the local region?
My belief is that as long as there are zoonotic diseases in any one part of the world that are not attended to, the rest of the world is at risk. So, it is important that we address and stop them quickly where they emerge. If we know enough about the disease to prevent it, we should do everything we can. We need to take responsibility, as members of a global village, to make sure that we prevent the spread of these diseases.
Animals don’t respect borders. Take avian influenza, for example -- the birds can cross borders so quickly. Especially in this region, where we have so much wildlife, disease can spread swiftly to any part of the world.
Can you tell us about the 2007 outbreak of Ebola in Bundibugyo?
The Ebola outbreak in Bundibugyo was a very big national challenge. I was working at the Ministry of Health as an AFENET Fellow, providing technical support to the ministry. I had been in Atlanta, Georgia, on a training [at the Centers for Disease Control and Prevention], and two days after I returned, I was sent [to help with] a plague outbreak in the West Nile region. While I was there, they called me and said, “Please, can you come? We have something in Bundibugyo which seems to be coming from animals.”
At first, it was not clear that it was Ebola. It was different from what we had known Ebola to look like in the past, where people are bleeding and dying so fast. This started slowly, and the cases were not so typical. At that time, people thought it was coming from goats.
So I moved from West Nile [to Bundibugyo]. The team of health workers there was doing tremendous work. They had tried to contain the spread; they didn't know what it was, but they knew it was being spread by contact, so they put up some isolation. By this time, a specimen had been tested in Atlanta, and it was negative for Ebola.
We decided it would be a good idea to test the people who had recovered; so we went back and took their specimens and requested them to be tested again for Ebola. Since the survivors had a lot more antibodies in their blood, which were readily detectable, the laboratory in Atlanta was able to confirm that this was a different strain of Ebola. But it had taken us six weeks of investigation without confirming that it was Ebola.
So this was a totally new strain of Ebola?
It was a new strain, modified from the others. This strain was also different in the way it presented. In these particular cases, people were living up to three weeks, and there was very little bleeding. They would develop a rash; then they would recover a bit with treatment, sometimes for Malaria or sometimes with antibiotics. Some cases were even discharged, but then they came back, and they would deteriorate and die. The normal case fatality rate for Ebola is 80 percent. It could even be 100 percent. But with this strain, we only had 40 percent. It is still very high, but I have to commend our workers there; they really worked very hard to save those people. The origins of this outbreak are still a mystery. There has been a follow-up study to look at monkeys and bats, but it’s yet to be confirmed. So, it is still a mystery.
What was it like to be a health worker in Bundibugyo at that time?
This outbreak greatly affected the way people lived. It was very, very scary. I remember when my colleagues and I came back, we brought a specimen, and then a few days later, the investigators announced, “This is Ebola.” Literally the whole team became sick, psychologically. We had the medical knowledge, so we were saying to ourselves, “Well, if I contracted it, I don’t want to infect my family.” Some of the health care workers went back to Bundibugyo, just to be there, away from their families. Or they said, “OK, if I’ve already contracted it, I’ll be more useful there.” The health workers were really scared because they saw their colleagues dying. Usually, in Uganda, when people are sick, neighbors and relatives come to visit. A number of those visitors died in this case, and it started to cause stigma. Individuals who recovered found that, when they went home, they weren’t accepted into society. Or their house had been destroyed because people thought they were going to harm them. So it was very, very stressful emotionally. As part of the response, we actually had to set up psychosocial care.
Can you tell me about the plague outbreaks in Uganda?
The most recent plague outbreak was in West Nile -- the northwest bit of Uganda that lies west of the River Nile. There are places there where we have persistent plague. The most recent outbreak was in 2008. This was my fourth time responding to a plague outbreak, and it was very sad because quite a number of young people had been affected. Two little boys were trying to do exams, and they had these swollen and painful buboes and high fever. But if they missed these examinations, they would have to wait for another year. So, they were trying to do their examinations, and yet at the same time, that was delaying their treatment. If you don’t treat that bubonic form, it can become systemic, and then it will become pneumonic. We had close to 100 cases that time and more than14 deaths.
How do people contract plague there?
In the West Nile, we have a rat called the Nile rat, which lives in the fields. The rats have fleas, and the fleas transmit the plague. But the Nile rat is resistant to plague, so the plague bacteria can grow in the rat and be passed on from one generation to the next, without the rats getting sick. The Nile rat burrows in the ground and in the bushes. But during the rainy season, after we’ve harvested the fields, the Nile rat has no food and its burrows are filled with water. Then, since it can’t find food or shelter outside, it moves into human homes.
Inside the houses, we have another type of rat, called the black rat or the house rat. This rat is very susceptible to plague. So when the Nile rat brings infected fleas into the house, these fleas bite the house rat and infect it, and it dies very quickly. After the house rat dies, its fleas have very high doses of the germ because it was very heavily rooted in the house rat’s blood. Fleas don’t like dead things, so within five minutes, all the fleas move. They need another source of food, and the human being is usually the one who is immediately available. So that’s why a plague outbreak is usually preceded by a massive death of rats.
What are the symptoms of plague?
Depending on where this flea bites you, the plague germ will enter your blood and move to the lymph node glands -- usually in the mandible, armpits, or groin. The bacteria cause these glands to swell and to become very big and extremely painful. If the person is treated and the problem doesn’t progress, then it's just considered a bubonic plague case. But if you don’t treat it, the germs break out of the bubo, and they will either enter blood or go to the lungs. If they enter blood, they start multiplying very fast, and we say you have septicemic plague, which is very dangerous but usually not transmitted to other people. If the germs go to the lungs, then you start coughing, and the disease can spread. But the good news is that, when you start treatment, the germ quickly dies: Within two days the patient should be safe.
Are zoonotic diseases more dangerous to people than diseases that have only one host species?
Zoonotic diseases are dangerous because they have a reserve outside the human population, which makes them very difficult to control. For example, with cholera, once you change human behavior, it is easy to eradicate. But when you have an animal reservoir, especially a wild animal reservoir, it becomes more difficult. I do not think it is possible to address zoonotic diseases simply through public health. The control of zoonotic disease essentially lies in putting a barrier at the animal level, so that the diseases either do not infect animals, or they do not jump from animals to humans. That is why the “One World, One Health” concept is actually the best answer, if only we can figure out how to make it practical.
For example, in Uganda, we've been trying to address plague for a long time. We go there, we investigate, we teach them. Next season, it comes again. So we decided that we have to change strategy. We have formed a multisector team that has medical officers, epidemiologists, statisticians, a zoologist, an entomologist, veterinarians, an engineer, an architect, and a sociologist. These different people come together and say, “What is the problem?” And then we identify the right point of intervention, and they go out together. Right now, the team is in West Nile; we have all the different people working together, and it has helped a great deal. It’s the end of September, and we don’t have plague cases.
So, we believe that this is a model that can actually be applied to all zoonotic diseases. For example, if I was just working as an epidemiologist, I would go to the village and tell the population, “You see, these rats come for food. Don’t keep food in your house.” And the people would keep quiet. But if I went to the sociologist and asked why people keep food in the house, I would learn that, if they keep their food outside, thieves take it. The people have a good reason to sleep with their food in the house. So then we ask the architect, “How can they keep their food safe?” And the architect says they can construct very cheap storage bins in their houses, which are not accessible to rats. The rats learn very fast they can’t get food from that house, and then they will go. So just by bringing the different professions together, we are able to address this. So we are working beyond just having professions and sectors. The common questions that challenge this approach are “Who’s going to have this in their budget?” “Who’s going to own it?”
The other aspect, which needs improvement, is the sharing of information. You find that people dealing with animal health are not aware of what diseases are occurring in humans. So they’re not even aware that diseases are coming from animals and infecting humans. And people working in human health are not aware of what diseases are actually in the animal population around them. So we have set up a mechanism for sharing information, with surveillance data from livestock, wildlife, and human health. Then, when we have a disease outbreak in one area, we can proactively prevent it in another area.
The international organizations have quite a big interest currently in “One World, One Health.” Now what we need to do is to come up with practical examples of how to make it work on the ground. And that’s what AFENET is essentially trying to do.
What motivates you?
I love my people. I went to the United States to train [in veterinary medicine], and I had this temptation to stay there, just like all my colleagues. And then I thought about my people, and I was like, “OK, I’m just one person, but I can make a small difference.” So I came back here and started teaching at Makarere University, which I did for 16 years. But then I felt I needed to be more directly involved in something that helps people, so I started field epidemiology training and got a Masters of Public Health. The beauty of my job is being able to understand disease from both sides, because I have worked with animals and I have worked with human beings. AFENET has given me a good platform because it's a young organization, and I can innovate.
I also think Uganda presents a very good opportunity for the global perspective: It's like a laboratory, because we have lots and lots of diseases. The ecology here supports so many pathogens, and it supports so many animal species. And the Ugandans have been able to work together to start building these systems. International partners that have come here have found that we are more willing to work together -- our universities are very enthusiastic about collaborating, and the government is willing and open.
It is my belief that Ugandans are going to make a difference in this country. But every African must take responsibility. What really makes me fulfilled is to see a life saved, to see that I have been able to make a difference. I’m just one person, but I want to take my responsibility and play my role. During my second plague investigation, I found these two graves, of a mother and a little baby. I felt so bad because they didn’t have to die of plague. I was determined to do whatever it takes to save one more life.