We Could Have Stopped This

World, you still just don’t get it. The Ebola epidemic that is raging across West Africa, killing more than half its victims, will not be conquered with principles of global solidarity and earnest appeals. It will not be stopped with dribbling funds, dozens of volunteer health workers, and barriers across national borders. And the current laboratory-confirmed tolls (3,944 cases, with 2,097 deaths) will soon rise exponentially.

To understand the scale of response the world must mount in order to stop Ebola’s march across Africa (and perhaps other continents), the world community needs to immediately consider the humanitarian efforts following the 2004 tsunami and its devastation of Aceh, Indonesia. The U.S. and Singaporean militaries launched their largest rescue missions in history: The United States alone put 12,600 military personnel to a rescue and recovery mission, including the deployment of nearly the entire Pacific fleet, 48 helicopters, and every Navy hospital ship in the region. The World Bank estimated that some $5 billion in direct aid was poured into the countries hard hit by the tsunami, and millions more were raised from private donors all over the world. And when the dust settled and reconstruction commenced, the affected countries still cried out for more.

In contrast, the soaring Ebola epidemic garnered only a negligible international response from its recognition in March until early July. The outbreak originated in the tropical rain forest of Guinea in December 2013, but local health authorities did not recognize the new disease in humans in the country until four months later. They can be forgiven a slow reaction, as Ebola has never previously appeared in the West African region. Shortly after the World Health Organization (WHO) officially declared an outbreak of the same strain of Ebola that first appeared in Zaire in 1976, outside humanitarian responders appeared on the scene to assist Guinea; they were the organizations that dominated the treatment and prevention efforts throughout the spring and into the summer, as Ebola spread to Liberia and Sierra Leone. During that time the outbreaks were largely rural, confined to easily isolated communities, and could have been stopped with inexpensive, low-technology approaches.

But the world largely ignored the unfolding epidemic, even as the sole major international responder, Doctors Without Borders (also known by its French acronym, MSF), pleaded for help and warned repeatedly that the virus was spreading out of control. The WHO was all but AWOL, its miniscule epidemic-response department slashed to smithereens by three years of budget cuts, monitoring the epidemic’s relentless growth but taking little real action. Even as the leading physicians in charge of Liberia and Sierra Leone’s Ebola responses succumbed to the virus, global action remained elusive.

The neglectful status of the WHO was, horribly, by design. Its governing body, the World Health Assembly (WHA), in which nearly every nation on Earth is a voting member, has declined to increase country WHO dues for more than a quarter-century. Worse, following the 2008 financial crisis, most of the extrabudgetary special support that the WHO relied upon — funds from rich countries that more than doubled the agency’s financing — disappeared as once-wealthy governments turned away from philanthropy while saving their fiscal skins. The WHO saw its revenues fall by more than $1 billion, and inflation-adjusted dues from member countries plummeted to pre-1990 levels. As Europe’s financial crisis worsened in 2010, speculators sold their euros in favor of Swiss francs, driving the value of that currency up 32 percent. Since the WHO receives its revenues in U.S. dollars, but makes its Swiss payroll and other payments in francs, the agency was forced to lay off 20 percent of its staff. And in 2011, the WHA began pressuring the Geneva-based WHO to decrease its infectious diseases work in favor of a radical increase in attention to noncommunicable ailments such as cancer and heart disease. The coup de grâce came with the 2012 WHA meeting, in which the nations of the world voted to chop the WHO’s crisis and epidemic funding by 50 percent, bottoming out this year at a mere $114 million.

As I wrote last month, the world simply didn’t get it. And it still doesn’t. The WHO doesn’t have a giant SWAT team of disease-fighting soldiers ready to swoop into a beleaguered area on an agency-owned transport jet, armed with lifesaving drugs and vaccines. In reality, the WHO begs airlines for tickets in coach, pleads with drug companies and protective gear manufacturers for free handouts, and has only the expertise on hand that governments are prepared to payroll and donate, such as scientists from the U.S. Centers for Disease Control and Prevention (CDC).

And now the epidemic is skyrocketing — nearly half of the cumulative case burden of Ebola in the three countries has occurred in just the last 21 days, according to the WHO. This week CDC Director Tom Frieden returned from Liberia visibly stunned, flabbergasted by what he had witnessed, warning that "There is a window of opportunity to tamp this down, but that window is closing."

Disease fighters reckon the contagious potential of an outbreak in terms of its RO, or reproduction number. (RO = 1 means that each infected person is statistically likely to infect one more person, so the epidemic will neither grow, nor shrink in size. RO = 0 signifies that the disease cannot be passed from person to person. Any RO above 1 connotes an expanding epidemic.) Christian Althaus of the University of Bern in Switzerland just released a grim new calculation of the RO for this epidemic that finds that when the outbreak began in Guinea, it was RO = 1.5, so each person infected one and a half other people, for a moderate rate of epidemic growth. But by early July, the RO in Sierra Leone was a hideous 2.53, so the epidemic was more than doubling in size with each round of transmission. Today in Liberia, the virus is spreading so rapidly that no RO has been computed. Back in the spring, however, when matters were conceivably controllable, Liberia’s then-small rural outbreak was 1.59.

The International Society for Infectious Diseases* operates a disease notification system called ProMED-mail, which on Friday noted that the spread of the epidemic is suddenly accelerating. From March to July 17, the first 1,000 cases accumulated over four and a half months. The toll reached 2,000 after just one month, on Aug. 13, and then jumped to 3,000 just 13 days later, on Aug. 26. If this trend continues the epidemic could well reach the WHO’s projected 20,000 cases by October. In extensive conversations with MSF and U.N.-associated responders in the countries it is clear that the WHO’s official case reports, which solely reflect lab-confirmed patients who have sought care in medical facilities, under-represents the true toll by at least half, as families are keeping their sick at home and shunning health facilities.

There are two factors contributing to the rate of spread: the genetic capacities of the virus itself and the behaviors of human beings that put them in contact with one another, thereby passing the virus. Though there is strong evidence that the Ebola virus is mutating and evolving right now as it passes through large numbers of people, none of the roughly 300 mutations detected to date have given the virus capacities that change its inherent infectiousness. So any change in the RO is due to people taking terrible risks, or lacking equipment and knowledge to protect themselves.

Moreover, there are increasing reasons to fear that tracking and quarantine in Nigeria to prevent further spread there has also failed. The problem was initially confined to a small number of people in late July who accompanied and treated Liberian traveler Patrick Sawyer before he died of Ebola in Lagos. But one quarantined individual escaped to Port Harcourt, while another continued to treat patients and until he succumbed to the disease, possibly infecting more than 60 people. And there are reports of isolated cases of the disease in the capital, Abuja. Senegal’s capital, Dakar, is handling a case involving a traveler from Guinea. The epidemic threat is surely widening.

This week the WHO finally came out of its somnambulant state and infuriating claims of being just a "normative agency," as Director-General Margaret Chan has repeatedly put it. The WHO’s Chan and Keiji Fukuda, who oversees the agency’s responses to outbreaks, held a blitzkrieg of meetings in Washington this week hoping to raise hundreds of millions of dollars and instill confidence in United Nations leadership. With them was David Nabarro from the United Nations’ Secretary-General’s Office, who was recently appointed to coordinate Ebola responses across the entire U.N. system. They touted the WHO’s "road map," a 12-point set of principles and needs for Ebola response that was released in August. When the road map was originally released, the WHO said its implementation might stop Ebola in nine months’ time, at a cost of $490 million and some additional 20,000 human cases. But days later, at their Sept. 3 Washington press conference, Nabarro put the cost at "at least $600 million" and said that "it may cost even more," and "scale-up needs to be on the order of three to four times what is currently in place."

The take-home message of the road map boils down to this: Stopping Ebola is going to require a great deal of money, thousands more skilled health workers and logistics experts, massive communications efforts, huge food and nutrition support for the people of West Africa, and "coordination, coordination, coordination."

"Coordination," as Nabarro said, "saves lives."

All that coordinating will presumably be executed from an "Ebola Crisis Center" created on Sept. 5, and located in the U.N.’s New York headquarters. But here is what WHO and U.N. leaders have not said or explained to date.

First, where is the bank account to which donors, both public and private, can make out their checks? Surely the logical location is the World Bank, but months after the epidemic commenced there is still no account to which a corporation like Goodyear (which has huge rubber operations in Liberia) or Rio Tinto (mining in Guinea) or Titanium Resources Group (Sierra Leone) can donate millions. If a list of celebrities wishes to mount a "We Are the World" campaign, or social media fundraising begins in earnest, there is still no centralized, accountable, transparent repository for the funds.

Second, nearly all commercial airlines and air delivery companies have stopped flights to and from the three Ebola-stricken nations, and many have halted services across all of West Africa. As a result, personnel and supplies cannot get into the area, and exhausted health volunteers desperate for a break cannot get out. Nabarro flew to Liberia last week — or tried to. The airlines refused to fly, and he reached Monrovia through a circuitous set of connecting flights.

Happily, the government of Ghana has agreed to make Kotoka International Airport in Accra an air bridge for Ebola responses, allowing large aircraft from all over the world to land at Kotoka, and smaller planes to shuttle personnel and supplies in and out of areas of need in the region. The WHO will assure that screening is in place at all of the region’s airports to ensure that no ailing individuals fly to Ghana.

While this is a long-overdue beginning, the air bridge — if it is to come close to meeting the needs in the Ebola-stricken areas — will require military-scale logistics and support. Having landing rights is only step one: Knowing where to warehouse goods, tracking their fate, loading secondary aircraft with proper destinations, and ensuring absence of theft are massively complex activities — just ask FedEx. Given the positive relations between Washington and Accra, it seems logical that the U.S. Air Force should supply transport flights and personnel, as well as warehousing and logistics support at Kotoka. To get a sense of the scale of the necessary Kotoka operations, Fukuda has calculated that for every 80 patients in care in Liberia, for example, 200 to 250 health and logistics personnel are required. And MSF has shown that fatigue and stress prompt errors in personal protective behavior that risk Ebola infection. To fight this, all of MSF’s foreign volunteers are flown out to neighboring countries every few weeks for R&R, while others are rotated in as replacements. Simple math based on the number of cases currently estimated and the joint Fukuda/MSF calculus shows that more than 11,000 health care workers are needed now, with exigencies destined to soar with expansion of the epidemic. No matter where these people come from, most will need to use the Kotoka air bridge.

But also not stated in the road map or WHO/U.N. briefings is who will pilot and crew the planes in that air bridge? Chan said that her team has been meeting with airline executives, trying to convince them that the safety of their personnel can be assured. But it seems unlikely that hundreds of commercial pilots, cargo handlers, and flight crew will volunteer to fly in and out of Liberia, Sierra Leone, Guinea, and even, if conditions worsen, Nigeria. Military pilots and crew, in contrast, often volunteer for dangerous missions.

Supplies of everything from basic food for the people of Monrovia’s slums to advanced medical equipment are desperately needed, and demand for everything will grow in tandem with the size of the epidemic. If the Ebola RO in Liberia = 3.0 right now — and it might — then the expansion rate of personnel and supplies needs to grow threefold simply to keep pace, or fourfold to get ahead of the virus. The logistics and warehousing scale of need is mind-boggling — akin to FEMA mobilizations to tornado-stricken communities or the recent movement of supplies to the Philippines following Typhoon Haiyan in 2013. But WHO and U.N. leaders have nothing to say about staging grounds, warehousing, and accountability for the movement (versus theft and black-marketing) of supplies.

Some countries abutting the epidemic have refused to serve as staging grounds, even for warehousing of crates of gloves and surgical gowns. Though the names of these governments are whispered off the record, WHO and U.N. officials have said nothing on the record about this obvious breakdown in global solidarity. Will nations that refuse even to allow humanitarian planes to land on their real estate pay any political price?

Similarly, some countries in the region have refused to allow exhausted health workers and international volunteers entry for vital R&R respites. One of the logical places for this — a country that is famous for its luxury hotels and dining — now privately tells the U.N. that MSF and other groups will only be allowed to "rest" at the airport, and may not stay in the nation’s hotels or facilities. Will countries pay any price at all for such approbations? Unless the offenders are publicly named, it seems doubtful any price will be paid for such ungenerous national behavior.

The WHO and U.N. leaders decline to speak on the record about any use of outside military personnel in support of domestic operations inside impacted countries, though MSF recently issued a call for military support, specifically from the United States. (As I write, no official response to the request has been released by the U.S. Department of Defense, but its Canadian counterpart appears to have declined to provide military support.)

There are a number of reasons the presence of foreign military personnel on African soil should be carefully considered. On the one hand, local police and military forces are stressed to the limit, many having been attacked by mobs of angry citizens. Just as health workers merit R&R, so too do the exhausted proponents of law and order. Foreign soldiers and police may be helpful. The U.S. military has the most sophisticated mobile response capacity and experience in the world, having been in combat on more than two fronts since 2001. MSF can see the benefits of putting those medical boots on the ground. Washington officials say off the record that options for U.S. military assistance are under consideration, and may be announced in a few days.

But beyond bringing in military personnel to handle the logistics and air bridge support, the presence of uniformed foreign military personnel risks feeding conspiracy theories that already surround this epidemic. The classic canard of every modern epidemic — that the germ was made or distributed by the CIA — is already circulating in these countries. The existing "uniform" of hoods, gloves, goggles, and protection suits has already sparked anger and suspicion. A visible foreign military presence could not only fuel further suspicion, but fan Islamist claims in Nigeria that infidels are contaminating vaccines. Any non-indigenous military use must be carefully considered, weighing the tremendous professional skills and experience combat medics could bring to the epidemic fight against potential blowback from conspiracy-mongers and Islamists.

In addition to failing to address basic logistics, warehousing, financing, and military issues, U.N. and WHO leaders have not been willing to discuss what happens to their road map if Ebola spreads in Nigeria or Senegal, the two richest and most cosmopolitan nations in West Africa.

The WHO’s Chan has been at great pains in her media blitz this week to say that the U.N. and WHO are not in charge — the respective governments are in command of the Ebola crisis. But Sierra Leone and Liberia are among the poorest countries in the world, with weak governments that constantly struggle to overcome public distrust sown by years of brutal civil wars. Unanswered is the obvious question: What does the world community do if a weak government fails to act, or makes wrong choices? If Ebola spreads to other countries this conundrum will arise again, and the global community will be left with its own question: "Who’s in charge?"

The weak, deficient road map might actually be strengthened if it received formal backing from the U.N. Security Council, with passage of specific resolutions calling for creation of centralized banking for Ebola responses, penalties for countries that decline to appropriately engage in the effort, at least $1 billion in immediate support, mobilization of food for the region to stave off imminent famine, and the like. The silence of the Security Council is stark, as the usual reasons for division and veto, especially on the part of Russia and China, do not apply in this case. If Ebola escapes its current confines, the risk of contagion is shared across the planet.

Having chronicled the 1976 Ebola outbreak in Yambuku, Zaire, and having been in the 1995 Kikwit epidemic, I have puzzled for long hours over the litany of failures in this current epidemic. This week I spoke with Barbara Kerstiens, who in 1995 was a young MSF physician assigned to lead just two other foreign MSF volunteers to handle the Ebola epidemic in Kikwit. I was filled with admiration watching them transform the General Hospital from a hellhole of festering disease lacking water, electricity, hygiene, or any modicum of patient comfort into a clean, electrified facility with fresh water and decent supplies. I asked Kerstiens, who now lives in Brussels, what made it work back in Kikwit, and discovered she had been pondering that question for weeks.

"We were all confronted with something we did not know much about, and/but were willing to take the risk, for many different reasons," Kerstiens wrote in an email. All of us, including this then-journalist, found ourselves in a situation for which there was no precedent, and, "We found ourselves doing different things from what we were ‘briefed on’ and we had/obtained the ‘go-ahead’ to improvise from our respective headquarters." The two MSF volunteers arrived with their instructions from European headquarters, as did the CDC scientists instructed from Atlanta, the WHO folks with Geneva orders in hand, and Professor Tamfun Muyembe, who took commands from Zaire’s dictator Mobutu Sese Seko. But once on the ground in the huge, yet remote town of Kikwit, everybody agreed to toss the dictates from their headquarters and reconsider the best uses of their skills and supplies.

Kerstiens credits Muyembe with warm and welcoming leadership. By nature gregarious and gracious, Muyembe was long-practiced in the school of charm, having worked miracles for years in getting around Mobutu and his corrupt government. A professor of infectious diseases at the University of Kinshasa, Muyembe was comfortable with the languages of science and medicine, and fluent in English, French, and at least two African languages. At his side, acting as co-leader, was David Heymann, who as a young CDC worker and then on assignment for the WHO had worked in Africa for many years. Heymann spoke French fluently, and handled African French dialects adroitly. Muyembe and Heymann liked and respected one another, their leadership was clear to all, and they saw themselves as "stewards" rather than perhaps "commanders" of the response, Kerstiens says.

Together with the courageous Kikwit Red Cross and students from a local medical school, the Ebola team "developed a clear plan of action," Kerstiens recalls. They were able to convey credibility and "create the atmosphere in the town of Kikwit of look guys, this is scary, but we have a grip — follow our guidance."

As in Kikwit, Kerstiens says, the Ebola responses in Liberia, Sierra Leone, Guinea, and possibly Nigeria each need a "national force/brigade that tells people, ‘this is what you do and what you do not,’ and that does surveillance — this brigade has to have the trust of the people."

The trust of the people: Attaining that is clearly the primary challenge these desperate governments face. And as time marches on, with Ebola spreading in toll and geography, the World Health Organization and the entire U.N. system will find themselves struggling to maintain trust among the people of this world and their governments.

*Correction, Sept. 8, 2014: The disease notification system called ProMED-mail is operated by the International Society for Infectious Diseases. An earlier version of this article mistakenly stated that the system is operated by the Federation of American Scientists and incorrectly called the system "Pro-MED." The Federation of American Scientists helped establish ProMED-mail in 1994, but the system has been operated by the International Society for Infectious Diseases since October 1999. (Return to reading.)