Was The Ebola Epidemic Preventable?

A NYT investigative report finds that “there was a moment in the spring when the longest and deadliest Ebola outbreak in history might have been stopped”, but failures of communication among health officials in West Africa enabled it to spiral out of control:

A two-month investigation by The New York Times into this largely unexamined period discovered that the W.H.O. and the Guinean health ministry documented in March that a handful of people had recently died or been sick with Ebola-like symptoms across the border in Sierra Leone. But information about two of those possible infections never reached senior health officials and the team investigating suspected cases in Sierra Leone. As a result, it was not until late May, after more than two months of unchecked contagion, that Sierra Leone recorded its first confirmed cases. The chain of illnesses and deaths links those cases directly to the two cases that were never followed up in March.

Since then, West African authorities and international organizations have followed a steep learning curve, Alexandra Ossola writes, but containing the outbreak (which the WHO reports has now infected over 20,000 people) remains a daunting task:

The WHO and others have disseminated info​rmation about proper burials to dissuade families from conducting funeral practices that may cause further infection, and they have been pretty effective. But there are still too many risky burials; Sierra Leone, which still has the highest number of cases, did no​t meet its December 1 goal of safe burials for 70 percent of victims.

… There are signs that these countries are fighting Ebola more effectively, [CDC spokesperson Kristen] Nordlund said, but challenges remain. Health care workers are still struggling to contain Ebola’s spread in cities like Freetown, Sierra Leone. When people move across borders between countries with high infection rates, tracking down the people who may have come into contact with a patient becomes extremely challenging. Some hospitals still don’t have enough beds to safely treat infected patients, Nordlund said, and not all regions have sufficient number of medical personnel to do the necessary follow-up with those who may have been exposed.

Meanwhile, a group of scientists has put forth a theory as to how the outbreak made the jump from animals to its first human victim, a two-year-old boy from the remote Guinean village of Meliandou:

Reporting in the journal EMBO Molecular Medicine, scientists led by Fabian Leendertz at Berlin’s Robert Koch Institute delved into the circumstances surrounding this first fatality. The finger of suspicion points at insectivorous free-tailed bats — Mops condylurus in Latin — that lived in a hollow tree 50 metres (yards) from the boy’s home, they said. “The close proximity of a large colony of free-tailed bats… provided opportunity for infection. Children regularly caught and played with bats in this tree,” the team said after an exhaustive four-week probe carried out in April.

In other Ebola news, another returning health worker has carried the disease home with her, this time in the UK. Scottish nurse Pauline Cafferkey was diagnosed yesterday after returning from Sierra Leone, where she had been volunteering along with other NHS health workers:

Ms Cafferkey, who had been working with Save the Children in Sierra Leone, arrived in Glasgow on a British Airways flight on Sunday but was placed in an isolation unit at Gartnavel Hospital on Monday morning after becoming feverish. [Scotland’s First Minister Nicola] Sturgeon told journalists that as a precaution, Health Protection Scotland has traced and contacted, or left messages with, 63 of the 70 other passengers who were on the same flight from London to Glasgow as the patient.

We Might Be Over Ebola, But Ebola Isn’t Over, Ctd


The latest YouGov poll illustrates how quickly Americans have moved on from freaking out about the disease and the government’s response to it, indicating that media sensationalism and partisan politics infected far more Americans than Ebola ever will:

Republicans have exhibited the greatest change.  At the end of October, 67% of Republicans said the government wasn’t doing enough to contain the Ebola outbreak.  That percentage has dropped 28 points.  Just 39% of Republicans now say the government isn’t doing enough. There is also less interest in increasing government spending to deal with the outbreak.  Just one in four today would increase government spending on Ebola research, down from 36% at the end of October.

But perhaps the most striking example of public satisfaction with the government’s performance is the change in the way Americans evaluate the President’s performance.  For the first time in two months, more Americans approve of the way Barack Obama is handling this situation than disapprove.

Josh Marshall even suspects that Christie has quietly retired his draconian quarantine policy for health workers returning from West Africa, though he can’t seem to get a straight answer out of the state of New Jersey. There’s also some good news on the international front:

the World Health Organization reports that the number of Ebola cases has stopped increasing in Guinea and Liberia, though they are still on the rise in Sierra Leone, while Mali seems to be keeping its second minor outbreak under control.

But even if outbreaks have peaked, that doesn’t mean these countries’ troubles are over. Last week, Abby Haglage called attention to warning signs of an “Ebola famine” in Liberia:

[Last] Tuesday, Mercy Corps published (PDF) a shocking finding: 90 percent of Liberian households are reducing the amount of food they eat at each meal, and 85 percent are actually eating fewer meals than they were before the health crisis. In a country where food was already scarce, slimmed-down portions could be the difference between life and death. A vendor in Monrovia told Mercy Corps investigators that she and her eight children can no longer afford to eat 10 cups of rice a day. They’ve cut rations down to eight. Simultaneously on Tuesday, the UN Human Rights campaign released a statement warning that West Africa may be “on the brink of a major food crisis” due to Ebola.

A new World Bank report confirms just how much damage the epidemic has done to Liberians’ livelihoods:

To measure the economic impact of that devastation, the World Bank, Liberian Institute of Statistics and Geo-Information Services and the Gallup Organization conducted phone surveys and found that not only is a massive part of the country’s work force out of job, but food insecurity is worsening. Wage workers and the self-employed have taken the biggest hit, the report finds. Prior to the epidemic, more than 30% of working household breadwinners were self-employed, but now that rate is just above 10%. Many people lost jobs because their business or government offices closed.

The Mistake Of Fighting Ebola Like A War

The US government’s response to the Ebola crisis in West Africa has relied primarily on the Pentagon, whose resources and logistical capabilities would seem to make it a good choice to lead such an operation. Alex de Waal, however, argues that military-run relief projects are less efficient and more costly than civilian efforts led by humanitarian professionals:

When Air Force planes carry out airdrops of emergency relief, they are invariably much more expensive and less effective than their humanitarian counterparts. Army engineers have the equipment to construct flood defenses or temporary accommodation for people displaced by fire or water, but there is invariably much wastage and learning on the job (by definition, too late). Experienced relief professionals can list many of the downsides of bringing in the military:

they utilize vast amounts of oversized equipment, clogging up scarce airport facilities, docks and roads; their heavy machinery damages local infrastructure; they use more equipment and personnel in building their own bases and protecting themselves than in doing the job; their militarized attitudes offend local sensibilities and generate resentment; and they override the decision-making of people who actually know what they are doing.

In the days after the Haitian earthquake in January 2010, the U.S. Army was efficient at clearing debris, setting up an air traffic control system, and getting Haiti’s ports and airport functional. One third of the emergency spending in Haiti was costs incurred by the military. (The costing includes only additional or marginal costs for the deployment.) When the army moved into other relief activities, such as general health and relief programs, even those marginal costs were disproportionately high. Trained for battlefield injuries, army surgeons weren’t skilled at treating the crush injuries common in an earthquake zone. In West Africa today, militaries are providing an important air bridge, given that commercial airlines have stopped flying. But the United Nations could do the job more cheaply and efficiently—if it had the resources.

Comeback Christie?

In a radio segment yesterday, the New Jersey governor hinted that he’s still got his eye on 2016, calling the time he spent on the road stumping for other Republicans this campaign season “a good trial run” for himself and his family. Joseph Gallant casts Christie as the biggest off-the-ballot winner in this week’s elections:

Ben Dworkin, director of the Rebovich Institute for New Jersey Politics at Rider University in Lawrenceville, says Christie, as he heads into a likely 2016 run for the GOP presidential nomination, stands to benefit in three significant ways: messaging, fundraising, and favor-trading. “First, he got to try out his message all across the nation,” Dworkin told the The American Prospect. “One question about Christie is whether his political style will play in Topeka. He’s now had a chance to travel everywhere across the country to see what works and what doesn’t, all on the RGA’s tab.” …

“He got to meet every major donor in the Republican Party and all of the key political operatives,” Dworkin continued. ”Running for president is a massive undertaking and you need to build a national team that already knows the battleground states. He’s gotten to do that.” 

But Dworkin’s third point could be the clincher for the Garden State governor. “Christie was at the helm when Republicans won huge victories around the country. Not only will he be able to take credit for those wins, but he will have the invaluable resource of governors ‘owing him’ for all the help he provided.”

His actions on Ebola also scored him some points with constituents:

A new poll from Monmouth University shows New Jerseyans approve of his handling of the Ebola situation 53 percent to 27 percent — about two-to-one. The federal government’s response, by contrast, earns negative marks at 37 percent approval and 46 percent disapproval. In addition, Christie’s constituents approve 67-19 of quarantining Hickox after she landed at Newark Airport. Where Christie gets more mixed results is in his decision to release Hickox, amid pressure, to a quarantine in her home in Maine — a quarantine that she later flouted. Thirty-eight percent approve of Christie’s decision here, while 40 percent disapprove. … A recent poll showed 80 percent of Americans supported the concept of some kind of quarantine. So, quelle surprise.

Still, Kilgore just doesn’t see Christie’s tough-guy persona winning over anyone who isn’t already into it:

Here and elsewhere, we’re given the impression that Christie’s now “over” Bridgegate, and back to being the big brawling dominant force the MSM and Republican elites have always loved. … Let me ask you, though: does anyone think being a figurehead for the RGA in a good year is going to cut a lot of ice with the actual on-the-ground activists and voters who will determine the Republican presidential nomination? Is anyone impressed by this other than the people who never stopped loving him? I’ll believe it when Christie no longer has by far the worst approval/disapproval ratio among likely Caucus-goers in Iowa.

We Might Be Over Ebola, But Ebola Isn’t Over


Eric Posner offers the above chart as evidence that the furore over Ebola is dying down. But risk-communication experts Jody Lanard and Peter Sandman fear that Americans underestimate the still-serious risk of the outbreak reaching pandemic proportions in the developing world:

The two of us are far less worried about sparks landing in Chicago or London than in Mumbai or Karachi. We wish Dallas had served as a teachable moment for what may be looming elsewhere in the world, instead of inspiring knee-jerk over-reassurance theater about our domestic ability to extinguish whatever Ebola sparks come our way. We are glad that Dallas at least led to improvements in CDC guidelines for personal protective equipment and contact tracing, and belatedly jump-started front-line medical and community planning and training. But it doesn’t seem to have sparked the broader concern that is so vitally needed.

Americans are having a failure of imagination – failing to imagine that the most serious Ebola threat to our country is not in Dallas, not in our country, not even on our borders. It is on the borders of other countries that lack our ability to extinguish sparks.

Maryn McKenna seconds that:

Being someone who has a professional specialty of covering epidemics (HIV, the anthrax attacks, SARS, H5N1, H1N1, lots of smaller outbreaks), I reluctantly have to conclude: Lanard and Sandman are not being alarmist here.

Imagine that Ebola cannot be contained; think back to the events of this weekend; and then imagine that reaction multiplied thousands of times. It isn’t a big leap to the suspicion, disruption and expense that will then be triggered in response to any travelers from the region. From there, it isn’t much of a further leap to closed borders, curbs on international movement, disruption in global trade, cuts in productivity, even civil unrest and the opportunities that unrest offers to extremist movements. None of that is far-fetched, if Ebola is not controlled.

Michele Barry reflects on the systemic failures that allowed the outbreak to spiral out of control. From her perspective, “the solution to this Ebola crisis is not drugs, mass quarantine, vaccines, or even airdrops of personal protective gear”:

The real reasons this outbreak has turned into an epidemic are weak health systems and lack of workforce; any real solution needs to address these structural issues. When one physician or nurse is caring for forty to fifty patients, mistakes happen. WHO’s legally binding International Health Regulations (2005) requires wealthier countries to mobilize financial and technical support to help contain an outbreak such as Ebola, for which the Director General has called an international public health emergency.

Yet workforce scale-up has been disturbingly slow. NGOs like Médicins Sans Frontières were not equipped to deal with Ebola, and have been overwhelmed by the outbreak. Workforce volunteers for these NGOs have been slow to mobilize and fearful US hospitals have set up barriers by insisting that their employees taking unpaid leave or vacation time and then return to mandatory 21-day quarantines, often without pay.

But the governor of New York, for his part, has pledged to compensate any lost pay. Perhaps the federal government should step in with actual financial incentives – cash money – to encourage health workers still on the fence to head to West Africa.

How Soon Can You Get An Ebola Shot?

Paul Howard monitors the progress drug companies and government agencies are making:

If Uncle Sam doesn’t shell out the money to help develop and then buy an Ebola vaccine, no one else will. The Defense Threat Reduction Agency (DTRA), the only other major investor in countermeasures for early-stage research, wrapped promising drugs such as ZMAPP in red tape, and seemed more interested in publishing academic papers than in actually helping companies develop products. Not surprisingly, the government is not an effective pharmaceutical company.

Still, nothing focuses the mind of government bureaucrats like a global health crisis unfolding in real time on cable-news networks. The government and private companies are now fast-tracking vaccine-development programs. The National Institute of Allergy and Infectious Diseases at the National Institutes of Health is collaborating on developing Ebola vaccines with GlaxoSmithKline and NewLink Genetics. GSK hopes to get data from early-stage safety testing soon. If the vaccine passes, GSK intends to run a large trial with health-care workers in Ebola-affected countries by early 2015, if not sooner.

Dr. Jesse Goodman, the former chief scientist of the FDA, discusses the inherent challenges in developing a vaccine:

These are complex vaccines that involve a live virus and you always have to have very well-controlled production. Cost is one factor: I think it’s hard to predict, but these are not going to be inexpensive to produce. However, many public health experts have said that if we have a safe and effective vaccine, the cost mustn’t get in the way of it reaching communities.

With all experimental treatments, including vaccines, it’s really important not to make presumptions that they will work. It would really be a shame if we’re not able to learn what works and what doesn’t, for the next outbreak or if this one continues over an even longer period. A vaccine could be a really important tool, but if we don’t have solid studies that show that it works and is safe, I think it would be really problematic just to immunize huge numbers of people with a vaccine we don’t understand.

Meanwhile, Alexandra Sifferlin highlights a major research project at Emory University in pursuit of an effective treatment:

Scientists at Emory’s Children’s Center for Drug Discovery have extensively studied the development of drugs for HIV that stop the replication of the virus in the body. The center provided breakthroughs for HIV drug development and, more recently, the development of a drug for Hepatitis C. The viruses, though different, have similar replicating mechanisms (viral RNA replication), and now they think they can do it for Ebola.

The team, led by director Baek Kim, is fast-tracking a program to screen a library of over 10,000 chemical compounds that can treat viruses at the molecular level to see if one or more of them may show promise with Ebola. “We need to start screening many, many compounds,” says Kim, anywhere from 500 to 10,000 of them—each of which will be evaluated one by one. Emory chemist Raymond F. Schinazi, who discovered compounds used in multiple very successful anti-HIV drugs, will be working with five to 10 virologists, chemists and biochemists to get the job done.

Getting The Real Ebola Crisis Under Control


As the above chart illustrates, the epidemic remains a serious public health crisis in parts of West Africa. Nonetheless, Helen Epstein sees signs that the tide may be turning in Liberia, where “the number of new cases each week … is falling, not rising”:

In August, the streets of Monrovia were strewn with bodies and emergency Ebola clinics were turning away patients. Today, nearly half of the beds in those treatment units are empty. I’ve been here a week and have yet to see a single body in the street. Funeral directors say business is off by half. Of course, the situation remains very serious. More than two thousand have succumbed to the disease here since the outbreak began—along with thousands more in neighboring Sierra Leone and Guinea, according to the CDC—and Liberia faces looming economic and political crises. This fragile country urgently needs help—both for the well being of its own people, and for the safety of the rest of this interconnected world. But the epidemic is far from the cataclysmic disaster currently on display on American TV screens.

How did things get so bad in Liberia in the first place? Shikha Dalmia blames “a hopelessly dependent political class that stays in business by ignoring good governance and appealing to its Western benefactors”:

Unlike Nigeria, Liberia’s immediate reaction was not to marshal its domestic resources but to hold press conferences and appeal for international aid, points out Johannesburg-based Yale World Fellow Sisonke Msimang. Liberian President Ellen Johnson Sirleaf, a Nobel peace laureate, even penned an open letter to the “world” this week, plaintively crying that Ebola wasn’t a domestic problem but a global one that “governments to international organizations, financial institutions to NGOs, politicians to ordinary people in the street in every corner of the world” had a “duty” to combat through “emergency funds, medical supplies, or clinical capacity.” But the “world” has been supplying all of this and more to Liberia in spades. Indeed, Liberia is among the largest aid recipients on the continent, with about 75 percent of its budget supplied by aid agencies. It receives $139 per capita in loans and grants, according to World Bank figures, compared with Nigeria’s $11 per capita.

If Liberia has indeed reached a turning point, that’s likely in part because the extremely poor communities where the virus has spread most rapidly, and whose residents often mistrust the government and aid workers (recall August’s attack on an Ebola treatment center in Monrovia), are becoming more knowledgeable about the disease. Abby Haglage profiles a UNICEF initiative called Adolescents Leading an Intense Fight Against Ebola, or A-LIFE, which has put some very dedicated Liberian teenagers on the front line of the information war:

UNICEF’s group was formed in 2012, with the intention of teaching young girls how to protect themselves from sexual violence. The worsening of the Ebola epidemic forced them to teach the girls about a new enemy. They learned what the disease is, how people get it, what happens then. Most important, they learned what they could do to protect themselves. Learning that gave them something the rest of their community, still reeling from the violent government-imposed quarantine, did not have: knowledge. So they walked. From house to house, day by day, teaching the community what they had learned. Ebola is real. It is deadly. Don’t shake hands. Wash them. …

The impact, to [UNICEF’s representative in Liberia Sheldon] Yett, is one only these girls have the authority to make. “They are far more powerful as spokespeople and educators than a public-health official could ever hope to be because they come from that community, they’re known by that community,” he says. “People understand where these girls are coming from, and people believe their messages.”

Yet even if things are looking up for Liberia, Keating cautions, there is still a ton of work to be done to get the regional outbreak under control:

All the same, we’re far from out of the woods in the fight against the disease that has already killed in the neighborhood of 5,000 people around the world. There have been no similar reports of drops in the other countries affected by Ebola. In fact, the number of cases has risen sharply in Western Sierra Leone this month. The disease also may have spread to yet another country—82 people in Mali who came in contact with a toddler who died of Ebola last week are currently being monitored for signs of the disease. The collateral damage from the outbreak—including the impact on the economies and political institutions of some of the world’s most fragile states and the setback in the fight against diseases like malaria—will continue to mount.

Update from a reader:

I work at a large hospital associated with a famous university and medical school. Both hospital and the university are routinely listed toward the top of all rankings of such institutions. My hospital has carefully laid out practice and policy set up for handling Ebola patients. Both my hospital and the university have long traditions of public service, and are not-for-profit. Both entities are renowned for commitments to humanity, education, research, and the elevation of the impoverished. Justice, beneficence, and respect for persons, as it were.

And both have explicitly forbidden any medical staff from traveling to West Africa to participate in Ebola treatment, public health, and eradication efforts. Nevermind quarantines and pay for time off. It is forbidden even if we have the time and don’t want the money (Though, I’m a researcher and not a clinician, so I’d have little to offer on the ground on site in West Africa.).

We talk about the need to prevent this epidemic from growing by addressing the situation at the heart of the outbreak. And it seems that people with the currently active strain of Ebola who are treated from the onset of symptoms with competent and comprehensive medicine are very likely to survive. Yet the death rate in Africa has been as high as 70% in places, because access to even basic medical care, must less excellent care as we have here (access to that care being a conversation for another day), is deplorably lacking. We will not contain this epidemic, and Ebola will become a daily fact of life in many places, unless more resources are brought immediately to bear at the source of the outbreak.

And yet, our esteemed institutions of medicine and science are issuing edicts that thwart any discussion of that possibility, regardless of our federal policies.