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~ “God gave Noah the rainbow sign, No more water, the fire the next time.” ~ James Baldwin, 1961
~ “Millions of people in sub-Saharan Africa today fall prey to infectious diseases because they are poor and suffer from malnutrition. Many infestations are treatable, but lack of access to clean water and adequate nutrition and poor sanitation lead to reinfection. Many Africans are caught up in a vicious web of poverty and disease.” ~ Aaron Buseh, 2008.
~ “Not one disease but wave after wave of new illnesses hitting in rapid succession did most damage to South America’s native populations. The combination of smallpox, measles, typhus, malaria, typhoid, mumps, influenza, yellow fever and, later, cholera, took a terrible toll of human lives. When such sicknesses coincided, the mortality levels were fearsome; 50, 60, 70 per cent of those infected succumbed. ~ Noble David Cook, 1998
~ “The SARS crisis developed quickly. It reached two continents in a matter of weeks. Worldwide attention and concern was focused on the situation. It was highly fatal; 10 percent of clinically ill people succumbed to the disease. This contrasts with the 1918 influenza pandemic’s mortality rate of 2.5 percent. That killed 40 million people worldwide, and remains etched in history as the most fatal in the human community in modern times. As the mortality of SARS became apparent, the risk and need for extraordinary controls was sobering.” ~ Anne Marie Kimball, 2006
~ “Viruseswill continue to evolve. Areas of the world left undisturbed will come under the saw, the ax, the plow and soon a virus new to human society or to now-stressed wildlife, will burst into highly noticeable outbreaks or epidemics. If we cannot avoid these occurrences, and it appears we cannot, at least we can try to predict them and be prepared to counter them.” ~ Charles Calisher, 2014
~ “A central feature of re-emerging epidemics such as HIV, malaria and tuberculosis is their transnational nature. But absent an urgent local need, long-term implications of transnational diseases are rarely addressed.” ~ Kumaranayacke & Walker, 2002.
~ “ A strong health system allows for effective response to pandemic disease, something only 20 percent of the world’s nations are currently prepared for. The tools that enable emergency response—a well-trained workforce, an information system to support surveillance and data sharing, a solid infrastructure for clinical care and laboratory analysis, and strong management of the health sector—are essential pieces of the health system.“ ~ Institute of Medicine, 2014
Watching the alarm here in America and across the world about the expanding ebola epidemic in West Africa has left me with decidedly mixed emotions.
I am a survivor of a 1987 severe tropical virus infection – contracted in West Africa. So, I know all too well how easy it is for such viruses – like ebola and the one I caught – to spread rapidly across borders and around the world. I know their life-threatening severity.
I worked at the World Bank for close to three decades including in West African countries. So, I know the challenges very poor people face are great even in normal times. Health care systems are so much weaker than in America, they are almost embryonic. Sanitation and nutrition are endemically low. Tackling the sudden onslaught of an epidemic such as ebola – with a high mortality (over 50%) – without considerable timely assistance from outside is all but impossible. The outcome at best risks to be devastating to the three countries – Guinea, Sierra Leone, Liberia – with such small, isolated and largely rural populations. Of course, it could be immeasurably worse if it were to spread in far larger scale across the world.
Mankind has been hit periodically with catastrophic epidemics for centuries. The biggest have left indelible marks on the world. Not the Spanish “conquistadores” but multiple epidemic diseases from Europe killed off ninety percent of South America’s native populations – 30 million – in a little over one hundred years (1550-1660). The “Spanish Flu” of 1918-19 – that actually began in Kansas ! – killed 40 million worldwide. The 2003 SARS (severe acute respiratory syndrome) pandemic mortality rate was more deadly and its scope global – reaching Europe and North America – within weeks.
But there is a major qualitative difference in our time: rapid economic growth, greatly increased international trade and travel, and climate change are causing increased ecological stress to our planet. They are driving viruses, and other human pathogens – like e coli and salmonella, and BSE (mad cow’s disease) – to multiply more rapidly and increase their geographic range across the world. Viruses are rapidly adapting to the natural world humans are transforming with growing population and insatiable demand for more food, especially meat. So, in seeking treatments (vaccines, serums) and containment methods, scientists and health professionals are literally chasing a moving target!
Key Questions : How did the recent outbreak of ebola in West Africa come about? Are there parallels to recent epidemics elsewhere? How likely is it such epidemics will become more frequent in the future? Is our global community prepared – scientifically and politically – to cope? What should we do now to contain the ebola epidemic ?
West Africa Ebola Outbreak : Ebola suddenly appeared for the first time in West Africa in Macenta – a small town in southern Guinea – in late December 2013. The region’s population had expanded rapidly – tripling since 1996 – due to refugees from civil wars in Liberia and Sierra Leone. Initially the outbreak was limited – with only moderate spread to Guinea’s capital Conakry. But in June 2014, a more virulent mutated virus spread rapidly into neighboring Sierra Leone and Liberia. All but non-existent local public health facilities,combined with regional travel and trade, carried the virus within weeks to the two countries’ capitals, Freetown and Monrovia.
Initial misdiagnoses, inadequate treatment and poor medical facilities enabled ebola to take off and reach epidemic proportions. Now the infected population is doubling every three weeks. So far, there have been at least 20,000 cases (but perhaps double that) and over half of those have died. By early November, left unchecked, the epidemic could reach over 50,000 – with a worst case scenario of one and a half million by end-2014. That would mean almost ten per cent of a total population of twenty million, only six months after the outbreak began! Unsafe burial traditions together with general lack of adequate sanitation are rapidly spreading the virus in overcrowded cities as well as rural areas.
Containing ebola has been badly held back by extremely limited public health facilities. This has been made much worse as many doctors, nurses and health workers have become infected and died. Even before, Guinea, Liberia and especially Sierra Leone had among the weakest health systems in the world. Poverty is very high – over 75% of people live on less than $2 a day, and do not have access to clean sanitation. Two thirds suffer from malnutrition.
Ironically, after decades of civil strife, the three countries – especially Liberia and Sierra Leone – had finally seen rapidly rising prosperity. With that had come a big increase in livestock production. Viruses like ebola are zoonotic – they cross-over from animals to humans. So cramped, insanitary livestock conditions could have helped trigger the epidemic. But, unlike with SARS in Guangdong, China, efforts to identify and isolate the animal source of the virus have so far been very limited. Instead, hopes are pinned on international efforts to quickly develop an ebola vaccine from trials of prototypes underway.
A major call has been put out for international help. And belatedly stepped up efforts are being made to send assistance. Especially now that a few cases occurred in Europe (Spain, Germany) and in the U.S.A. (Dallas, New York City). But the widening scope of the epidemic means these are insufficient to stop the virus spreading. More assistance is urgently and desperately needed.
Comparisons with Other Epidemics : There has been rising concern about ebola spreading to America and to Europe. But compared with SARS in Asia in 2003, so far ebola’s global reach has been far slower and very small, even while its lethality locally in Africa has been very high. Most likely this is because of far lower levels of inter-continental trade and travel with Africa compared to Asia. That is offset somewhat by more lax airport departure controls than the rigid “no fly” rules quickly put in place in affected cities in Asia. Both the ebola and SARS epidemics share some key features : They arose from a virus that jumped from animals to humans. And both were likely due to poor sanitation, especially for livestock.
Immediate Actions and Future Implications : The immediate need is to halt the spread of ebola quickly. With terribly weak and now depleted local health services, this will require a major effort from other nations – especially in the developed world. Sending outside volunteer doctors and nurses and health workers in large enough numbers and very soon will be key. As will far more abundant supplies of medical equipment, protective gear, and medicines. Alongside this, more work must be done to track and collect data on infection and mortality rates, and to search for the animal source of the virus.
Emergency food aid will be crucial. The World Bank estimates the three countries’ economies could shrink 5-10% by 2015. Even more worrying, malnutrition is increasing due to greater joblessness and closed food markets. This means convalescing survivors will be even more prone to follow-on disease, if not helped now. More than just NGOs – like Mercy Corps – that are planning to do so, donor governments need to step up food aid now. In the three countries, more rigid “no fly” rules are needed to prevent travel by infected people. Rather than rigid flight bans to America and Europe, this would keep the international economy moving while selective quarantines are used, as proposed by the CDC.
Long-Term Where Do We Go ? : The ebola outbreak will most likely prove less lethal outside Africa than did the SARS epidemic in 2003. But this should be no cause for complacency. This epidemic points once again to the rapid spread of new and virulent viruses across our planet. The implications for West Africa are quite devastating socially, economically and politically. Especially if the virus spreads strongly beyond the three main affected countries. And such trends are set to continue and intensify in the coming decade. Africa – and other poor regions – will trade more with the rest of the world, and will grow economically. They will become more urbanized, and livestock production will continue to rise. But they will still have weak sanitation and health systems. So the risks of even more major outbreaks are rising.
Global capabilities to handle this challenge are weak, out-of-date and under-funded. A key problem is the chronic lack of international support – especially from more advanced nations – to build much stronger transnational health systems. Preventing a modern day Spanish Flu or SARS epidemic – with worldwide impact – would have immense benefits to all humanity. But financing and running the necessary public health systems and medical research will not be done by the private sector or NGOs alone. Far stronger government backing is needed, even while public-private partnerships are also key. Key areas to focus on will be : ~ much expanded research on the seventeen neglected tropical infectious diseases of poverty (NTDs) that include ebola; ~ building stronger basic public health systems – in terms of data gathering, information systems, and dissemination for earlier screening, detection and treatment; ~ greatly strengthening health systems of poor countries, from which increasingly new viruses and pathogens will emerge; ~ creating an international permanent stand-by rapid response force – trained and capable of deploying quickly in response to emergency. This effort needs to be cross-sectoral and multi-disciplinary. It should also give high priority to giving all humans access to clean water and adequate sanitation, and improved nutrition; and to improving livestock rearing conditions.
Its global impact may ultimately be more limited than SARS. But the 2014 ebola epidemic is indeed a wake-up call. I, for one, hope that the world’s political leaders – and all of us – heed it. As James Baldwin told us, we need (clean) water to avoid the “fire the next time”.