Experimental drugs and airport screenings will do nothing to stop this plague. If Ebola hits Lagos, we're in real trouble.
- By Laurie GarrettLaurie Garrett is senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize winning science writer.
Attention, World: You just don’t get it.
You think there are magic bullets in some rich country’s freezers that will instantly stop the relentless spread of the Ebola virus in West Africa? You think airport security guards in Los Angeles can look a traveler in the eyes and see infection, blocking that jet passenger’s entry into La-la-land? You believe novelist Dan Brown’s utterly absurd description of a World Health Organization that has a private C5-A military transport jet and disease SWAT team that can swoop into outbreaks, saving the world from contagion?
Wake up, fools. What’s going on in West Africa now isn’t Brown’s silly Inferno scenario — it’s Steven Soderbergh’s movie Contagion, though without a modicum of its high-tech capacity.
Last week, my brilliant Council on Foreign Relations colleague John Campbell, former U.S. ambassador to Nigeria, warned that spread of the virus inside Lagos — which has a population of 22 million — would instantly transform this situation into a worldwide crisis, thanks to the chaos, size, density, and mobility of not only that city but dozens of others in the enormous, oil-rich nation. Add to the Nigerian scenario civil war, national elections, Boko Haram terrorists, and a countrywide doctors’ strike — all of which are real and current — and you have a scenario so overwrought and frightening that I could not have concocted it even when I advised screenwriter Scott Burns on his Contagion script.
Inside the United States, politicians, gadflies, and much of the media are focused on wildly experimental drugs and vaccines, and equally wild notions of “keeping the virus out” by barring travelers and “screening at airports.”
Let’s be clear: Absolutely no drug or vaccine has been proven effective against the Ebola virus in human beings. To date, only one person — Dr. Kent Brantly — has apparently recovered after receiving one of the three prominent putative drugs, and there is no proof that the drug was key to his improvement. None of the potential vaccines has even undergone Phase One safety trials in humans, though at least two are scheduled to enter that stage before December of this year. And Phase One is the swiftest, easiest part of new vaccine trials — the two stages of clinical trials aimed at proving that vaccines actually work will be difficult, if not impossible, to ethically and safely execute. If one of the vaccines is ready to be used in Africa sometime in 2015, the measure will be executed without prior evidence that it can work, which in turn will require massive public education to ensure that people who receive the vaccination do not change their behaviors in ways that might put them in contact with Ebola — because they mistakenly believe they are immune to the virus.
We are in for a very long haul with this extremely deadly disease — it has killed more than 50 percent of those laboratory-confirmed infections, and possibly more than 70 percent of the infected populations of Liberia, Sierra Leone, and Guinea. Nigeria is struggling to ensure that no secondary spread of Ebola comes from one of the people already infected by Liberian traveler Patrick Sawyer — two of whom have died so far. That effort was expanded on Wednesday, when Nigerian health authorities announced that a nurse who had treated Sawyer had escaped her quarantine confinement in Lagos and traveled to Enugu, a state that, as of 2006, has a population of about 3 million. Though the nurse has not shown symptoms of the disease, the incubation time for infection, which is up to 21 days, hasn’t elapsed.
Since the Ebola outbreak began in March there have been many reports of isolated cases of the disease in travelers to other countries. None has resulted, so far, in secondary spread, i.e., establishing new epidemic focuses of the disease. As I write this, one such isolated case is thought to have occurred in Johannesburg, South Africa’s largest city, and another suspected case reportedly died in isolation in Jeddah, Saudi Arabia, prompting the kingdom to issue special Ebola warnings for the upcoming hajj. It’s only a matter of time before one of these isolated cases spreads, possibly in a chaotic urban center far larger than the ones in which it is now claiming lives: Conakry, Guinea; Monrovia, Liberia; and Freetown, Sierra Leone.
So what does “getting it” mean for understanding what we, as a global community, must now do?
First of all, we must appreciate the scale of need on the ground in the three Ebola-plagued nations. While the people may pray for magic bullets, their health providers are not working in Hollywood, but rather in some of the most impoverished places on Earth. Before Ebola, these countries spent less than $100 per year per capita on health care. Most Americans spend more than that annually on aspirin and ibuprofen.
We must collectively listen to the pleading and anguish coming from those courageous health providers who have seen Ebola claim more than 80 of their colleagues since the crisis began. What do they want?
On Aug. 8, the World Health Organization (WHO) declared the Ebola epidemic a “public health emergency of international concern.” In its pronouncement, the agency noted the urgent need for local government actions, such as the recently erected cordons sanitaires, and for global mobilization of medical resources. The WHO has repeatedly warned that this epidemic could persist for a minimum of six months, perhaps a year. The director of the U.S. Centers for Disease Control and Prevention, Dr. Tom Frieden, has concurred with that grim forecast.
“It’s like fighting a forest fire: leave behind one burning ember, one case undetected, and the epidemic could re-ignite,” Frieden recently told Congress. “Ending this outbreak will take time, at least three to six months in a best case scenario, but this is very far from a best case scenario.”
At the same congressional hearing, Dr. Frank Glover, a medical missionary who partners with SIM, a Christian missions organization, and the president of SHIELD, a U.S.-based NGO in Africa, warned that Liberia had fewer than 200 doctors struggling to meet the health needs of 4 million people before the epidemic. “After the outbreak that number went down to about 50 doctors involved in clinical care,” said Glover.
I myself have received emails from physicians in these countries, describing the complete collapse of all non-Ebola care, from unassisted deliveries to untended auto accident injuries. People aren’t just dying of the virus, but from every imaginable medical issue a system of care usually faces.
Ken Isaacs, vice president of international programs and government relations at Samaritan’s Purse, the aid organization that has two of its members fighting for their lives in Ebola quarantine in Atlanta, told Congress, “It took two Americans getting the disease in order for the international community and United States to take serious notice of the largest outbreak of the disease in history. That the world would allow two relief agencies to shoulder this burden along with the overwhelmed Ministries of Health in these countries, testifies to the lack of serious attention the epidemic was given.”
Despite current response mechanisms, this Ebola outbreak, Isaacs said as he closed his remarks, “is uncontained and out of control in West Africa.”
Even if the world dodges a viral bullet and Ebola fails to take hold in a metropolis in a different country (such as Lagos, Johannesburg, Delhi, or Sao Paulo), controlling the disease and saving lives in Liberia, Sierra Leone, and Guinea will require resources on a scale nobody has delineated. The emotionally distraught doctors and nurses on the front lines are screaming for help.
Let’s start with simple, on-the-ground manpower. All three countries desperately need doctors, nurses, medical technicians, ambulance drivers, Red Cross volunteers, epidemiologists, and health logistics experts. They do not need novice do-gooders from the wealthy world, but people experienced in working under the stifling conditions of tropical heat, the desperation of supplies deficits, and the fearfulness of epidemics. The lion’s share of care to date has been provided by one group — Médecins Sans Frontières — which is pleading for others to relieve their exhausted ranks: 600 people who have been fighting for months on the front lines in this war.
Nothing could be clearer than this MSF press release, dated Aug. 8:
Dr. Bart Janssens, MSF Director of Operations
“Declaring Ebola an international public health emergency shows how seriously WHO is taking the current outbreak; but statements won’t save lives. Now we need this statement to translate into immediate action on the ground. For weeks, MSF has been repeating that a massive medical, epidemiological and public health response is desperately needed to saves lives and reverse the course of the epidemic. Lives are being lost because the response is too slow.
Countries possessing necessary capacities must immediately dispatch available infectious disease experts and disaster relief assets to the region. It is clear the epidemic will not be contained without a massive deployment on the ground from these states.
In concrete terms, all of the following need to be radically scaled up: medical care, training of health staff, infection control, contact tracing, epidemiological surveillance, alert and referral systems, community mobilisation and education.
MSF currently has 66 international and 610 national staff responding to the crisis in the three affected countries. All our Ebola experts are mobilized, we simply cannot do more.”
Here is the list of supplies Emmet A. Dennis, president of the University of Liberia, emailed that he needs for his medical school personnel now fighting cases in Monrovia:
Gowns — Isolation
Underpads — Disposable
Gloves, Examination — All Sizes
Body Bags — Adult & Children
Infectious Waste Bag — Red
Face Mask — Duckbilled
Face Shield — Disposable
Eye Shields — Disposable
Aprons — Disposable
Surgical Caps — Disposable
Scrubs (L & XL)
Thermometer: Infrared — Thermofocus
It simply does not get more basic. As there are no miracle drugs for Ebola, the needs include few medicines, though other local responders tell me that they wish they had sterile syringes, saline drips, and fever modulators such as aspirin.
“Getting it,” in this epidemic, means realizing that over the next six to 12 months, these countries will needs millions of dollars’ worth of basic supplies, hundreds of highly skilled health care workers, including logistics supplies officers, and self-sufficiency for all foreigners (food, water, personal supplies). As the border blockades ending trade to these nations persist, food supplies for the population will also become acutely short, probably necessitating World Food Program assistance. Exhausted, frightened young soldiers and police will need their ranks replaced slowly with United Nations Peacekeepers or soldiers from the African Union.
And of course this list assumes Ebola remains confined in terms of secondary spread to Liberia, Sierra Leone, and Guinea. If the virus takes hold in another, more populous nation, the needs will grow exponentially, and swiftly.