Michael T. Osterholm is the director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
Ebola outbreaks have occurred in Africa on more than two dozen occasions over the past 40 years, and they were brought under control every time. This was possible thanks to reliable techniques, such as preventing direct contact with infected persons and monitoring all people who did come into contact with an infected person. Anyone showing early symptoms was put in isolation. Despite no effective treatment or vaccine, these standard approaches worked.
Unfortunately, today’s outbreak is very different. And unless we invest more resources in fighting it — and coordinate the response across countries — the outbreak will spread further. If that happens, economic and political chaos could follow.
What’s different about this outbreak? The Ebola virus hasn’t changed; Africa has changed. First, residents of the affected countries — Guinea, Liberia and Sierra Leone — travel much farther and have many more contacts than they did in previous decades. Following up on all contacts who live a few miles from a case is much easier than tracking down people who may live far away. With modern transportation, family members may travel hundreds of miles to be with sick loved ones. And more of this outbreak area, in West Africa, is urbanized than where many of the previous outbreaks occurred in Central Africa, so the virus spreads faster.
Relatives may have extensive contact with an infected person before he or she dies, or they may help prepare the body for burial. Funeral traditions in Africa frequently involve washing the body before it is buried, which can mean contact with blood and other infectious bodily fluids. Public health workers haven’t been able to curtail this traditional practice; it’s a challenge that puts religious and cultural beliefs in direct conflict with infection control. Moreover, this is the first time that this part of Africa has experienced an Ebola outbreak, so there is no collective memory of what to do to stop the virus.
Second, local populations have been increasingly unwilling to cooperate with medical personnel and public health workers, in part because they believe that such workers are spreading the virus. While this is not a new phenomenon, faith in traditional medicine and public health measures alike has declined since previous outbreaks. As a result, cases are not being identified, and follow-up with contacts isn’t adequate enough to thwart transmission. This is happening much more frequently than it did during previous outbreaks.
For the past two months, the nongovernmental organizations providing the primary response to the Ebola outbreak have realized that the response from regional governments and international public agencies was inadequate. Their call for additional resources, including personnel and supplies, went unaddressed. Now, ending this outbreak will require a much more extensive public health response than has been needed in the past.
In addition, some people are hiding potential cases because they fear that their loved ones will be moved to a clinic or a hospital and placed in isolation, where they will die alone. These concerns are fueled by a lack of education about how the Ebola virus is spread and the difficulty in treating it. People see that their loved ones are alive when they are taken away — but are returned in body bags.
Since the first Ebola cases were reported in March from forested areas in southeastern Guinea, the outbreak has grown steadily in terms of people infected and geography covered. The virus has infected more than 1,300 people; more than 700 have died. This is nowhere near the tolls of other infectious diseases, such as HIV/AIDS, malaria, diarrheal disease and tuberculosis, which occur every day in this same region. But the Ebola virus strikes a chord of fear unlike other infectious diseases because of the quick, horrible deaths it causes.
The front-line providers of medical care for this outbreak have been dedicated and heroic, but there just aren’t enough of them. Doctors Without Borders is the primary treatment and community-intervention organization in the three affected countries, in addition to the International Federation of Red Cross and Red Crescent Societies, public health agencies organized under the World Health Organization (WHO), and in-country health-care providers and community educators.
These groups know how to fight this disease — they helped develop the interventions that stopped Ebola outbreaks in the past — but the nongovernmental organizations are “dangerously close to being completely tapped out,” a Doctors Without Borders spokesman told me this past week. “It will be impossible to implement an effective control strategy for this outbreak due to a severe shortage of medical professionals on the ground and the geographic spread of the disease.”
The Centers for Disease Control and Prevention announced Thursday that it will send 50 additional specialists to West Africa to help combat the outbreak, supplementing the 12 CDC professionals already there. For an outbreak involving three countries with about 22 million people and 165,000 square miles, that’s hardly enough boots on the ground. But the CDC is just one piece of the international response; the WHO and other G-7 nations need to act, too.
The WHO does not have the resources to stop this outbreak alone. With a deep respect for the sovereignty of the affected countries, the G-7 nations — the United States, Canada, Germany, Britain, France, Italy and Japan — must immediately mobilize and deploy hundreds of infectious-disease experts, along with medical and technical assets to map the epidemic. Hundreds more personnel will be needed to establish treatment centers and to work with local leaders and educators to help people learn how to stop virus transmission.
In addition to these outside resources, the affected countries must step up their commitment to stopping the outbreak. This past week, Ernest Bai Koroma, president of Sierra Leone, declared an Ebola-related public emergency. He called on the army to quarantine Ebola-stricken neighborhoods and to help conduct house-to-house searches for people who may have been exposed to the virus. Such moves acknowledge that this outbreak will not be stopped using the approaches that have worked before. But it is unclear how these efforts are being coordinated with the WHO and NGOs in Sierra Leone. And since this is a regional problem that requires every involved country to halt virus transmission, regional governmental coordination is crucial.
What happens if the response to and management of this outbreak don’t shift? The fear and panic are growing each day, with new areas reporting cases and more health-care workers dying. If it continues, West Africa could become politically and economically destabilized. Already, crops are not being harvested because of unrest surrounding the outbreak. Schools in Liberia have closed, and the Peace Corps has removed 340 volunteers from the affected countries. Borders are being closed, too, which can have political and economic impacts.
This coming week’s U.S.-Africa Leaders Summit in Washington must put the Ebola crisis front and center. If the presidents of Guinea, Liberia and Sierra Leone decide to stay home, it will be virtually impossible to do so. Other African countries must also pledge quick and effective responses if cases occur within their borders. We are at a critical point, and the response by the international community and the affected countries will determine if this outbreak is just a chapter in the region’s story — or a dramatic and dangerous shift in West Africa’s future.