Ebola's Hard Lessons
September 5, 2014
As September opened, a striking consensus had emerged among global health leaders that the Ebola outbreak in Liberia, Sierra Leone, and Guinea has transmuted into a colossus that continues to gather force: It is "spiraling out of control" (Dr. Thomas Frieden, Director of the U.S. Centers for Disease Control and Prevention, CDC); “We understand the outbreak is moving beyond our grasp” (Dr. David Nabarro, Senior UN System Coordinator for Ebola Disease ); Ebola is “a global threat” that “ will get worse before it gets better, and it requires a well-coordinated big surge of outbreak response” (World Health Organization Director General Dr. Margaret Chan); “Six months into the worst epidemic in history, the world is losing the battle to contain it. Leaders are failing to come to grips with the transnational threat” (Dr. Joanne Liu, Doctors Without Borders (MSF) International President).
Ebola in West Africa has overwhelmed the containment and treatment measures attempted thus far, and is seriously threatening nearby and neighboring states. (A separate Ebola outbreak is underway in the Democratic Republic of Congo, DRC.) Research and development of treatments and vaccines has accelerated, but the speed with which the Ebola virus is mutating has complicated the quest to identify new tools quickly. No tested or approved therapies exist. Vaccine testing has begun, but it is uncertain when or if a viable vaccine will become available. In the future, any viable vaccine will become effective only if people are immunized on a mass scale.
Up until now, high-level global statesmanship has been absent, and the modest, late steps taken to control the outbreak have failed to stop its alarming, exponential growth. As Ebola in West Africa charges ahead, it may finally stir world leaders to initiate the large-scale international security actions and other measures – quick disbursement of funds, mobilization of thousands of health workers, arrival of medical products and protective equipment – essential to arrest this catastrophe. If not, we should prepare for the worst: a runaway Ebola epidemic of an ever more massive scale in Africa.
As of August 28, the World Health Organization (WHO) estimated 3,069 cases with 1,552 deaths, over 40% emerging in the previous three weeks. By middle of this week, those numbers climbed to over 3,500 and 1,900, respectively. Over 240 health workers have become sick with Ebola, half of whom have died. This stark, upward, exponential trajectory is set to continue. WHO now freely admits that official numbers “vastly underestimate” reality and that the actual figures may be two to four times these levels. Total cases may soon reach 20,000, but there is no reason to believe it will stop at that level. Accordingly, in its new action plan, WHO called initially for international commitments of $489 million, almost five times the $100 million it proposed in late July. By this week, Dr. Nabarro claimed the requirements have reached $600 million but “could be a lot more.”
A tragedy for West Africa, the Ebola crisis has been a humiliating setback for the field of global health, full of hard lessons.
Up until now, there has been a wholesale failure to rally high-level political leadership, resources, and authoritative action in a timely fashion that can offer hope of truly getting out in front of the virus. Ongoing analyses of what is driving the outbreak, what scale it will reach, and what it will take to arrest it have frequently been incomplete and inaccurate, failing to capture the gravity of the human tragedy and the fierce propulsion of the epidemic. International and national efforts have fallen far short of what is truly required. The most optimistic estimate is that the present response meets no more than 25-30 percent of today’s requirements.
Several organizations have struggled on the ground and made important contributions. MSF, battle-tested in countless other violent, broken places (e.g., Rakhine, Myanmar and eastern Syria) has shown remarkable valor, discipline, and stamina in the face of the epidemic. It accounts for fully two thirds of treatment and care, an astonishing sign of both its achievements and how forbidding the West African environment is to most other NGOs, international bodies, and national governments. The United States has invested $21 million in protective gear, chlorine bleach, and food aid, and has deployed 100 personnel, 75 from CDC and 25 from the U.S. Agency for International Development. On September 4, USAID pledged an additional $100 million in disaster assistance, three quarters of which will go towards treatment facilities, additional U.S. medical personnel, delivery of medical equipment and other needs.
WHO, which according to its mission should be leading the global response, has been enfeebled by severe budget and staff cuts and has been “painfully slow” to respond, according to a New York Times editorial. In the acid words of one observer, Ebola is to WHO what Katrina was to FEMA in 2005. MSF is at its limits and cannot possibly continue to shoulder the lion's share of responsibilities. In the meantime, staff on the ground are becoming steadily more vulnerable – to infection and to violence – requiring greater investments to ensure their protection.
The new WHO roadmap, though late, incomplete, and clumsily assembled, is nonetheless a welcome step that does lay out plans for expanded support to hospitals, treatment centers, safe burials, and public campaigns, along with accelerated delivery of protective gear and essential medical supplies. However, the plan is silent on how the international community can move expeditiously from current commitments, totaling a mere $66 million, to the more than $600 million now required. While the World Bank has made a commitment of $230 million, and the African Development Bank $60 million, the authors of the WHO plan seem uncertain how these funding streams fit within the larger appeal. Nor does the WHO roadmap spell out who will direct the overall strategy, who will actually implement the ambitious operational goals, and most importantly, how the grave security hazards will be overcome. To be at all effective, new, additional capacities will be needed, in leadership, security, financing, strategic direction, and oversight. On the ground, several thousand additional workers capable of implementing emergency disaster programs are needed, and will require protection and expedited training and deployment. These critical elements are each needed urgently today, but where will they come from?
Health experts have been late in grasping the “shadow” epidemics, in which persons exposed to or sick with Ebola have gone underground. Officials were overly confident in the spring and later in mid-summer that measures that worked during earlier outbreaks would be possible and sufficient to arrest the outbreak in three to six months’ time. Instead, the disease quickly jumped from one to three to now five countries, and spread from remote rural areas into urban populations of coastal centers (for the first time ever), stoked by pervasive distrust, fear, woeful health infrastructure, the devastation of internal war in Sierra Leone and Liberia, and decades of malgovernance and virtual statelessness in Guinea. Shocked by the scale and speed of the epidemic’s spread, experts themselves have experienced a humbling erosion of confidence, replaced by bewilderment and confusion. For an anxious public watching the Ebola crisis unfold day by day, the debate has shifted: if, as WHO predicts, cases will soon reach 20,000, what will stop them from reaching 100,000?
Ebola in West Africa is no longer simply a public health problem. Fundamentally, it is a security challenge, which bears far more resemblance to the 14th century plague than it does to previous Ebola outbreaks, particularly as countries resort to crude upcountry “cordon sanitaires” and ill-advised, ineffectual urban quarantines that incite violence. It has triggered an existential crisis of multiple dimensions and raised the specter of a Hobbesian future in which acutely weak states simply cease to function and fall prey to worsening internal conflict. It has eviscerated already marginal health systems; triggered food insecurity that now affects over 1.4 million; gravely damaged production, markets, and economic growth; led to the collapse of air links; and prompted the sudden exodus of talent across diverse sectors. Risk of infection in the coastal capitals and other areas hit hardest by Ebola in Liberia and Sierra Leone has become so high that medical personnel simply cannot be effectively protected – whether at work or not.
Why have the world’s leaders not risen to the challenge? Why has the UN Security Council not taken up Ebola in West Africa? Part of the answer is overconfidence that what had worked before would contain this far different, more dangerous outbreak: early detection and laboratory confirmation of cases; containment and isolation of those that are sick or exposed; contact tracing, and safe burials. Part is that pleas from health experts were simply not heeded at higher political levels. Part is that this crisis has been a vast unknown, an unprecedented cascade of catastrophes, a 'perfect storm,' that few could foresee. And part is the limited opportunity this summer for high-level international consideration of a virus-driven security crisis in West Africa, a region of marginal significance in global terms. Sadly, as Ebola has mushroomed, it has thus far competed unsuccessfully for attention with the three urgent geopolitical crises of Russia-Ukraine, the Islamic State in Iraq/Syria, and Israel-Palestine.
What is to be done?
First, the UN Security Council needs to exercise its leadership – and to act, if there is to be a true surge response. Most importantly, it needs to empower a senior body to take charge of the international response, in concert with West African states, and to oversee the finances, security, personnel, and other resources that are required to realistically arrest the spread of Ebola in the region. WHO needs to be an integral element, but clearly lacks the capacity to lead.
Second, the first order of business needs to be the establishment of security, mobility, and significant financial liquidity. These steps are essential to putting into operation functional beachheads that permit the safe deployment of the several thousand critically needed health experts and emergency managers, the safe operation of laboratories and treatment centers, the functionality of supply chains, and the delivery of food relief. MSF International President Dr. Joanne Liu, in her September 2 statement to the United Nations, made a compelling case for one option to address the security gap and urgent need for mobile laboratories and field hospitals: “To curb the epidemic, it is imperative that States immediately deploy civilian and military assets with expertise in biohazard containment. I call upon you to dispatch your disaster response teams, backed by the full weight of your logistical capabilities.”
The United Nations has mounted dozens of Blue Helmet peacekeeping operations into dangerous settings before. Over 4,600 UN peacekeeping forces are deployed today in Liberia. The United Nations can and should be more engaged in West Africa now in mounting an international public health operation.
The United States’ military, possessing unrivaled lift capacities, has over the past three decades supported multiple international peacekeeping deployments into West Africa, directly and through contractors. These can and should be brought to the current fight.
These steps, if carried forward, will require the consent of West African partners, careful respect of sovereign sensitivities, and operational agreements. As Dr. Chan has emphasized in her warnings this week, the surge cannot be seen as a “takeover” by external interests that undermines the “confidence” and interests of West African states.
Third, it will be essential to keep a strong focus on what can work at the local, community level and to anticipate the difficult ethical quandaries that will abound, as those suffering and dying of Ebola continue to face cruel choices, compounded by stigma and isolation. For the near to medium term, the epidemic will swamp laboratory capacities, as well as treatment and care facilities. In the midst of this crisis, it will remain critical to find new innovative means, embraced by local community leaders, to deliver urgently on a large scale simple, low tech palliative care to Ebola's victims, and to create workable community-based approaches, tailored to different urban and rural settings, that can bring about consensual isolation and containment of the sick, voluntary quarantine of those exposed, and safe burial practices. Ultimately, progress made community by community will be the key to reduce transmission, illness and death.
There is still time for the world's leaders to act to stop the catastrophe of Ebola in West Africa. An ambitious, high-level, security-centered effort matched by innovative, low-tech community action has the best promise of transforming this rapidly escalating tragedy. But whatever strategy emerges, it will in this next phase call for considerable humility and creative new ideas, and will rest ultimately on the determined courage of the countless individuals who struggle daily to ameliorate suffering and fear, reduce death, and stop transmission of this deadly virus.