A little more than a year after the Ebola epidemic emerged, several authorities have begun to write about the lessons learned from the outbreak. But perhaps the most important of them all is that none of the lessons we supposedly learned from previous epidemics prevented Ebola, one of the simplest and best understood infections, from spreading uncontrollably through West Africa in 2014.
Scientists identified Ebola roughly 30 years ago. Since then, several outbreaks have cropped up that were small enough to be ignored by the international community. However, such outbreaks pointed to the greater impending danger that future policymakers would prove unprepared to address. This failure would stem in part from the human brain's limited ability to deal with very large numbers in an objective way, which can lead to the undertaking of gargantuan tasks that are grossly impossible to tackle. In the medical realm, this innate bias has manifested itself in unrealistic expectations of the ability of global health organizations to address transnational epidemics.
The widespread lack of insight into the root causes of the world's failures to address runaway infections does not bode well for its responses to new crises in the years to come. Until leaders in the international community acknowledge the actual extent to which mankind could implement a global disease prevention regime, and instead refocus their efforts toward goals that are more achievable, the world will remain woefully unprepared for any future outbreaks, whether they occur naturally, accidentally or as an act of bioterrorism.
Ebola's Place in the History of Epidemics
Though this column is not the place for a meticulous autopsy of the Ebola outbreak, a brief look at how the virus compares with other epidemics can shed some light on why the failure to prevent last year's crisis is worrisome.
Cycles of infection are a natural phenomenon in maintaining ecological balance. Epidemics occur when population densities and migration patterns break down the barriers that typically contain an infection's spread. Population growth rates have exploded since the agricultural revolution, meaning that recurrent epidemics are inevitable. While technological innovation can mitigate this threat to some degree, it could also become a source of epidemics, whether by accident or through biological warfare. Even now a runaway epidemic, though improbable, is one of the most likely disasters with the potential to kill millions of people.
14th-century Western Europe's Black Death is perhaps the most famous example of a horrible scourge that emerged suddenly, sweeping across continents and leaving devastated societies in its wake. Compared with the various epidemics identified since the Black Death, Ebola is relatively easy to quash because it is not as well adapted to target the human host.
Ebola patients usually start feeling sick within a week of coming into contact with the virus and become deathly ill within two weeks, displaying telltale signs of massive internal bleeding. Ebola cases are far easier to investigate and diagnose than those of patients suffering from kuru, a variant of mad cow disease that takes several decades to manifest, and even then only does so through vague symptoms that are shared by a wide range of illnesses.
The Ebola virus kills its victims in about 50 percent of cases, a far greater mortality rate than that of measles, which is in the single digits. However, diseases with lower mortality rates can in some ways be more insidious. Measles, for example, eradicates immunities that its host has already acquired, re-exposing the patient to illnesses that he or she has already conquered. Diseases that take longer to sicken or kill their hosts also give the infectious agent a greater opportunity to spread to more victims; agents that kill their hosts swiftly typically burn themselves out more quickly.
The clincher, though, is that Ebola is not transmitted by air but by contact with infected bodily fluids. Such diseases can easily be contained by implementing simple physical barriers, such as requiring handlers to wear clothing that fully covers their bodies and using sealed body bags to transport infected bodies. By comparison, airborne viruses such as severe acute respiratory syndrome (SARS) and measles are far more difficult to contain.
Thus the natural history of Ebola confirms that the virus has not adapted well to humans and should be, in theory and in practice, one of the easiest epidemics to prevent.
Unrealistic Expectations for an International Response
In an article published by the New England Journal of Medicine last month, philanthropist and Microsoft founder Bill Gates pointed out that the West is prepared to prevent wars through organizations like NATO, but the world has no such organization to prevent epidemics, despite the fact that outbreaks are certain to happen and that their costs are staggering. (The World Bank estimates that an influenza pandemic alone carries an opportunity cost of about $3 trillion.) Admittedly, the World Health Organization has a Global Outbreak Alert and Response Network, but it does not even begin to boast a level of "combat" capability and readiness comparable to that of NATO. This lack of preparedness is less a fault of the World Health Organization and more a symptom of the strategic failure in managing societal change not uncommon at the international scale.
For any system of disease surveillance to work, it must be able to rely on existing public health systems to spot, diagnose and confirm suspected cases. In a similar way, NATO exists as a superstructure that rests atop existing national armies with a local force presence and intelligence gathering capabilities. It comes as no surprise then that the Global Outbreak Alert and Response Network's most significant failures occurred in areas where basic health care systems were deficient.
An outbreak also requires rapid response teams that are specially trained, fully equipped and permanently on standby, not unlike those that NATO maintains in the event of an intervention in Eastern Europe. Yet in the Ebola epidemic, the only organization able to quickly send trained volunteers was Doctors Without Borders; the nongovernmental organization even trained members of the Centers for Disease Control and Prevention, which is undoubtedly the best funded and most professional infectious medicine institute in the world. Doctors Without Borders also managed to set up its first treatment unit within 18 days of the official request for assistance, a remarkable feat when compared with the massive U.S. relief effort to deploy a dozen treatment units to Liberia, which in the end treated only a handful of patients since they did not come online until the outbreak was already winding down.
A response to any epidemic on the scale of the Ebola outbreak requires a centralized command and control center. Though NATO would certainly succeed in this respect, the World Health Organization did not; it has admitted to taking an inexplicably long time to confirm the ominous warnings coming from medical workers in the field and to launch a relief effort. Still, the World Health Organization cannot take all of the blame. Even if it had managed to set up a strong command and control center, the lack of local health monitoring systems in place in certain areas of the world still would have prevented the organization from having a full picture of the outbreak or how it was spreading, which in turn would have made it difficult to estimate and prioritize resources for an intervention.
The World Health Organization (and the medical field more broadly) faces unique barriers to innovation that the military does not. Even though there were three different platforms for an Ebola vaccine in development when the outbreak began, the ethical and regulatory restrictions that govern the development of new medicines are not designed for emergency situations, blocking efforts to accelerate vaccine development or seek approvals for shortcuts. On top of that, clinical trials must be given as much time as they need; their underlying biological processes cannot be sped up for the sake of convenience to meet a particular demand. Militaries, on the other hand, have proved remarkably agile and adaptable to rapid delivery schedules.
Expectations of a global health organization that detects and combats disease much as NATO responds to conflicts are unrealistic. Putting aside, for a moment, the differences the military and medical field face in local capacity and innovation, consider the complexity of NATO itself: What did it take to assemble the countries that now serve as NATO members? If NATO's richer members are already balking at its costs, what are the chances of finding states that are willing and able to finance the underfunded and understaffed World Health Organization?
Perhaps, then, we should interpret the New England Journal of Medicine's willingness to provide Gates a pulpit as a subliminal acknowledgment by some of the world's most prominent medical policy authorities that the task of creating such an organization is beyond the capabilities of the international community. Mankind is biologically wired to respond to threats with fight or flight, and since it is nearly impossible to find refuge from a global epidemic, we have no option but to continue to fight. However, we would do well to steer clear of the massive waste that comes with wishful thinking, and should instead funnel our resources toward simpler goals that are actually achievable.