The worst-ever Ebola epidemic continues to unfold in West Africa, with no sign that it will be under control anytime soon. As of Saturday, there have been 397 deaths among the 706 confirmed cases (a 56 percent fatality rate) since reports of Ebola cases in West Africa began to emerge in March. The first cases of the epidemic were reported in Guinea, but additional cases were later reported in neighboring Liberia and then Sierra Leone. All three countries have poor health infrastructure and are struggling alongside international actors to stop Ebola’s spread.
A recent Washington Post editorial was pretty damning for the West African governments responding to the Ebola epidemic, but if we think about the constraints these governments face in their response, we shouldn’t be surprised. The editorial remarked that, “Ebola is not new… medical teams have always effectively segregated infected areas and stopped the virus’s spread. The method is understood: treat the patients, trace their contacts and isolate those people.” If only it were that simple.
Like other public health epidemics, local government response is often shaped by the actions of international actors and success is constrained by the public whose health they’re trying to secure. In my research, I refer to this as the “global supply chain” of a public health intervention. There are a lot of links in the chain — each link representing an opportunity for something to go wrong. In this post, I apply my framework to the current Ebola epidemic to identify potential explanations about why the response has yet to be effective in stopping the disease’s spread.
But first, what is Ebola, how does it spread and where is it now?
Ebola is an infectious virus that often results in death. Anywhere between 2 and 21 days after infection, patients’ early symptoms will include fever, weakness, muscle pain, headaches and a sore throat. The disease progresses to vomiting, diarrhea, impaired organ function and bleeding. There is no vaccine to protect against Ebola, and there are no specific treatments beyond managing symptoms of those infected. The primary goal in responding to Ebola, then, is to stop its spread by isolating those suspected of infection and raising awareness in affected communities on how to protect against infection.
Ebola is a zoonotic disease, meaning it is transmitted to people from animals; in the case of Ebola, the most likely reservoir is fruit bats. Then Ebola spreads between people as a result of coming into contact with the blood or bodily fluids of an infected person or through exposure to instruments contaminated with infected bodily fluids. The most at-risk populations are family members and/or health-care workers caring for those infected with Ebola because they come into close contact with infectious secretions.
Ebola infection is difficult to confirm, often requiring multiple blood tests. In some rural areas in Africa, strong beliefs about protecting one’s blood (our “life force”) only makes more difficult the necessary collection of blood specimens to confirm Ebola cases. The blood tests often used to confirm Ebola require a technologically advanced laboratory. Early in the epidemic, samples had to be sent to France, Germany and Senegal for testing. In Sierra Leone, there is only one laboratory capable of testing for Ebola. The limited availability of laboratory testing slows response.
The current epidemic is the first outbreak of Ebola in West Africa, and its geographic spread has been wide, with cases reported in more than 60 locations across three countries. This outbreak marks the first time that Ebola has been reported in a capital city — in this case, all three capitals of the affected countries: Freetown, Sierra Leone’s capital, which has an airport offering about 15 international flights per week (four to London); Monrovia, Liberia’s capital, whose airport has about 11 international flights per week (four to Brussels); and Conakry, the capital of Guinea, whose airport has about 13 international flights per week (three to Paris). Suspected cases have also been reported in Ghana, including an American citizen, but none of these was confirmed to be Ebola.
How concerned should a North American be about their risk of infection? There was a suspected case in Canada that was later confirmed not to be Ebola. Contrary to the concerns raised by retired physician and current U.S. Rep. Phil Gingrey (R-Ga.) that migrant children crossing into the United States from Mexico were carrying Ebola, there has never been an Ebola case reported in humans beyond the African continent (NB: Animals have tested positive for a much less severe strain in the 1980s and 1990s in the Philippines, the United States and Italy, and in the 2000s in China and the Philippines).
Why hasn’t the Ebola epidemic declined?
This answer isn’t as easy as pointing the finger at West African governments or poor health infrastructure. Nor can we simply blame poor international coordination by the world’s leading health organization. There are a number of reasons that we are yet to see a decline, and below I offer a few potential explanations.
1. Curbing the spread of Ebola doesn’t happen overnight.
One of the more successful Ebola responses was in Uganda in 2012. That epidemic claimed 17 lives among 24 confirmed cases. The Uganda outbreak occurred in a single country — meaning there was no need to coordinate across multiple governments. Uganda also had the unfortunate benefit of having experienced three previous Ebola outbreaks, from which the health community had learned lessons. Two years before the 2012 outbreak, the CDC set up a lab at Uganda’s Virus Research Institute specifically tasked with the rapid diagnosis of viral hemorrhagic fevers (including Ebola), reducing the time it took to confirm Ebola cases, which facilitated a quicker response. Even under these more favorable circumstances, the 2012 Uganda Ebola epidemic lasted 68 days.
The first confirmed Ebola cases in West Africa were reported March 21, 2014, meaning we are 116 days into the epidemic. A major contrast for this epidemic is that it is unfolding in a context that has no previous Ebola experience. At the same time, current epidemic requires coordination across three countries’ governments and health agencies, as well as a myriad of “partners.”
In resource-constrained settings, especially those with limited experience in responding to Ebola, response by international health experts is essential — but takes time. The amount of time it takes the international community to respond varies greatly. Only six days into the 2000 Uganda Ebola outbreak, the donor community financially supplemented the government’s Ebola budget (adding $400,000 to the government’s $285,000). There’s no available data for us to make an apples-to-apples comparison, but it seems that the international response has been quick in some areas, but not all (remember the wide geographic spread of the current epidemic). For example, Doctors Without Borders/Medecins Sans Frontières (MSF) sent a specialized team to Gueckedou on March 18, just six days after another MSF team already in Guinea (working on a malaria project) had learned from Guinea’s Health Ministry about what was then characterized as a “mysterious disease.” However, with respect to coordinating response across the countries, there seems to have been greater delay. For example, it was not until July 2 that the World Health Organization convened a special meeting bringing together ministries of health and partners involved in the Ebola outbreak to discuss a collective response. Only today is the WHO activating operations at a Sub-Regional Outbreak Coordination Center it recently established in Conakry.
2. These countries are ill-equipped to respond to Ebola, and some of what they’ve done in response doesn’t seem productive.
All three affected countries have poor health infrastructure. Health policy and surveillance documents and scholarly literature on health in Sierra Leone and Liberia often start with a statement akin to, “After more than a decade of civil war, there was near-total destruction of the health system…” Guinea didn’t fare much better; its resource-poor health system was overburdened by refugees fleeing the wars in Sierra Leone and Liberia. Health personnel are also scarce in these countries. For example, Liberia has just 0.014 doctors per 1,000 people.
Government responses to the epidemic aren’t helping. On June 30, Liberian President Ellen Johson Sirleaf proclaimed that the government would prosecute anyone “reported to be holding suspected Ebola cases in homes or prayer houses.” Sierra Leone President Ernest Bai Koroma made a similar statement. If we look for the good intentions in these leaders’ statements, we might attribute them with intending to increase traffic of suspected Ebola cases to formal health institutions, where people can be properly isolated, subsequently allowing others who may have come into contact with a suspected case to be traced, ultimately curbing the outbreak’s spread. But is the threat of prosecution the best motivation for increasing health-seeking behavior? If a government is ill-equipped to provide basic health services in far-flung regions of the country, how equipped is that same government to prosecute evasion of health care?
In Liberia, we know that people in rural areas actually have relatively high usage of formal health care, even in the face of serious “geographical and financial barriers to access.” Scholars recommended “focusing on quality of care rather than mobilizing demand for care” as high quality of services and availability of drugs are still problematic in much of Liberia.
3. The many actors involved in the Ebola response can actually complicate the response, especially if it’s unclear who is in charge.
Like most responses to infectious disease epidemics, there is a myriad of actors involved in the response to Ebola in West Africa. These include the local ministries of health of Liberia, Guinea, and Sierra Leone, the WHO, (MSF, CDC, UNICEF, Institut Pasteur, the European Mobile Laboratory Project (funded by the European Union), and others.
A significant challenge in responding to public health problems is coordinating across these actors. Part of the challenge is the lack of clarity on who should lead response efforts. As political scientist Jeremy Youde writes in his 2012 book “Global Health Governance,” though the WHO dominated international health governance immediately after World War II, existing organizations — intergovernmental organizations as well as private corporations, philanthropic organizations and civil society organizations — have expanded their mandates to cover global health issues, and new health organizations have emerged — leading to volatility in the WHO’s ability to be a leading voice.
4. Ultimately, the success or failure of the Ebola response relies on the ordinary people who are at risk of becoming infected.
There is little known about the beliefs and opinions on Ebola and response to Ebola of ordinary West Africans who are navigating the epidemic. What little we know about local perceptions are those reported by local journalists (see this on Sierra Leone) or by international health workers (see this on Guinea). However, these assessments of local perceptions of Ebola are not necessarily representative of the population of interest — in this case, those sick with or at risk of contracting Ebola. This population matters most for understanding how effective the response will be; their beliefs will shape their acceptance, rejection, or adaptation of the health messages being deployed at them. One solution is to draw from research about Ebola beliefs elsewhere on the continent. As one study of the cultural contexts of Ebola in Uganda showed, some cultural practices may have amplified the outbreak, but local people held beliefs and practices that could also be useful to control a rapid and high-fatality epidemic like Ebola. The authors concluded:
Because local people have lived with high mortality rates and serious epidemics for some time, their knowledge may be useful to national and international teams in their efforts to control emerging diseases.
Like most health interventions, a major component is spreading awareness about the disease, plainly, what it is and how to avoid infection. These awareness-raising campaigns rely on whether ordinary citizens believe the messages, which often must overcome strongly held notions about health and disease. At the same time, awareness-raising campaigns compete with rumors about and suspicions of government provision of health care and/or international providers of health care. Violence at a clinic treating Ebola patients in Guinea in April is one example – the crowd attacking the clinic accused MSF health workers of bringing Ebola to Guinea. In her research, sociologist Amy Kaler warns against simply characterizing rumors as representations of misunderstanding best dealt with by the provision of accurate information – and instead see them as more than the “absence of truth” and try to tailor public health responses that consider the power of existing rumors surrounding health/disease.
tl;dr — Responding to Ebola is complicated.