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Why we fail at stopping outbreaks like Ebola

A medical staff member wearing a protective suit walks past the crematorium where victims of Ebola are burned, in Monrovia, Liberia.
A medical staff member wearing a protective suit walks past the crematorium where victims of Ebola are burned, in Monrovia, Liberia.
Pascal Guyot/AFP

The Ebola outbreak has finally reached America.

On one hand, we're shocked: the hemorrhagic fever was previously only in West Africa, affecting people over there, far away, who did not have access to healthcare facilities and who do not all follow the best public-health practices.

But on the other hand, every expert knew it was just a matter of time before this disease went global. Viruses don't respect political boundaries. And the spread of disease like this across national borders is just business as usual.

Throughout history, there have been many global
epidemics. They rip around the world, leaving piles of dead bodies in their wake: the black plague of the 14th century wiped out up to 70 percent of Europe; the death toll of the 1918 flu pandemic grew to 75 million; and the ongoing HIV/AIDS pandemic has reached every country on the planet and has taken the lives of more than 30 million since the 1980s, when the virus was discovered.

Of course not all outbreaks are so catastrophic. But the catastrophic ones all start small, in only a few people. Then they infect a few hundred, then thousands, and then millions of people. Today viruses like Ebola spread quicker than ever before. Instead of moving across continents over decades, it now just takes them 14 hours to go from, say, Liberia to Texas.


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Spread of Bubonic plague in Europe. (From the World Health Organization.)

The US government has long known about this threat. It's one reason why the CDC spends so much time supporting public health institutions in developing countries, why the US Department of Defense invests so heavily in global disease surveillance, and why the National Institutes of Health is the most generous funder of investigator-driven global health research in the world. It's also why the White House launched a new Global Health Security Agenda last February 2014 – before the current Ebola outbreak – to get ahead of epidemic threats like it.

But this Ebola outbreak — and the failed response — shows in the clearest way how unprepared we are for global pandemics. International institutions like the World Health Organization have been starved for cash to the point that they can't lead effectively during crises. International laws, like the International Health Regulations which govern responses to pandemics, don't work in practice. And the US government has often led the way – with 'zero nominal budget growth' and 'no enforcement mechanisms' as its firm position on international laws.

To date, Ebola has killed more than 3,000 people this year, the largest-ever outbreak of this disease. It's bound to kill more. Even though the public health community knows from previous outbreaks how to contain it, we did alarmingly little to stop Ebola until very recently — and some say too late.

ebolamedia

Nearly five months passed from the time the World Health Organization (WHO) announced that Ebola was in West Africa (March) until this crisis was declared a "public health emergency of international concern" (August).

In August, we started to see unprecedented action, political will, and resources being poured into Ebola. But this surge response only came when it seemed to be politically expedient. As you can see in the chart above, leaders woke up to Ebola when public attention on the disease peaked following the news that two Americans had been infected in Liberia, weeks after Ebola cases had already started their exponential ascent.

We've known we can't actually properly respond to global disease outbreaks for years

The inadequate international response to Ebola has played out with other diseases in the past. The SARS scare in 2003 spurred 196 countries to revise the International Health Regulations that were supposed to improve responses to global health emergencies.

These regulations were meant to make the reporting of outbreaks more transparent and build out capacity for disease surveillance. Individual countries were supposed to pay to improve their disease surveillance and reporting systems, and richer countries were under an international legal obligation to support their poorer cousins.



But the H1N1 swine flu scare in 2009 showed that the changes didn't fully work. A high-level expert panel in 2011 reviewed the international regulations and concluded that the world is "ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency".

They found the WHO faced difficulties in leading the world's response, that states too often did their own thing despite the agreement, and that countries did not have all the public health capacities to actually comply with the regulations.

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Medical staff remove the corpse of a victim of Ebola from a house in Monrovia, Liberia. (Photo by Pascal Guyot/AFP)

For example, if a country doesn't have a strong disease surveillance systems in place — to report local outbreaks to WHO — the goal of the regulations can't be achieved. If a country doesn't have labs to test specimens for disease, again, the regulations won't work. And that's exactly what happened with Ebola in West Africa.

The countries where Ebola made the leap from its animal host (believed to be fruit bats) into humans this year happen to be three of the poorest in the world, and it took them at least three months to even realize they were harboring an Ebola outbreak.

Criticisms about the regulations have been well documented, with some observers saying they define pandemics too narrowly, others highlighting their vagueness, and still others emphasizing how they rely on political pressure for compliance since there are no formal enforcement mechanisms. Academics have also complained about how the International Health Regulations provide opportunities for politicizing pandemics.

Even if the these regulations were perfect, they have not actually been implemented by many countries — a concern noted by the G20 as recently as 2013. Yet, they continue to be the framework on which global disease responses rest.

The Ebola response was slow

With Ebola, this cycle is playing out again. The global health community essentially watched a slow car crash and did nothing about it until after it lit on fire and exploded,  shards of glass that are now hitting other countries.

It's not clear whether the interventions happening now will get to Africa quickly enough, and whether the commitments there will outlast public interest in the disease. This is disturbing because we know how to stop Ebola outbreaks. We've done it more than 20 times in the past through basic infection-control measures: isolating sick patients, avoiding their blood, vomit, and sweat, following the contacts of those infected to make sure they aren't falling ill too and quarantining those who do.

But we didn't stop Ebola this time. This crisis became so big, it outstripped our ability to contain it through these well-honed methods.

This has reduced countries to desperate measures: the US is sending in 3,000 troops to battle a virus. Sierra Leone has forced all of its citizens into repeated lockdowns to stop the disease from spreading further and root out hidden cases in door-to-door searches.

Many observers have put the blame on the WHO, pointing out that its slow response exacerbated this crisis. Some have said this can be attributed to budget cuts that have left the agency understaffed, under-resourced and demoralized.

Meanwhile, the WHO also insists it is just a "technical agency," tasked with providing analysis and data, and not providing political leadership or acting as a first responder. That means, while they aren't the ones who will give medical treatment on the ground, they'll provide guidance and evidence necessary to coordinate a response. But, as an editorial in the journal Nature pointed out, we don't have an alternative global health body. "If the WHO is not the first responder to an emergency such as this, then who is?"

We need to act on lessons learned

We've had outbreaks before, and they show us we're not prepared. Our global health systems have repeatedly proven themselves ineffective in identifying and responding to this kind of disease outbreak. We've known about these weaknesses and inadequacies for years yet have done little about them.

For disease outbreaks, it's clear we have to take lessons learned from past failures more seriously. Complacency has cost lives — in this outbreak alone, already more than 3,000  and counting.


Watch the Vox.com 2-minute explainer video about how this outbreak spun out of control

Those lessons learned point to action needed in at least two areas. The first is at the national level: countries' health systems must be strengthened. For poorer countries, this means prioritizing health in national budgets and renewing the focus on preventative public health measures rather than only curative medical care.

For richer countries, this means putting foreign aid dollars into public health systems — building up the infrastructure, establishing clear coordination mechanisms, developing preparedness plans, and expanding lab and surveillance networks, especially in the poorest countries.

These fixes are longer-term, harder to measure, and far less sexy than distributing medicines or building new hospitals, but they are what's needed most to save lives in this outbreak and the next one.

Richer countries also need to support poorer countries when health crises arise, such as through lending staff to a Global Health Emergency Workforce or financing an emergency International Health Systems Fund that countries can access as soon as outbreaks are identified. In the model we have now, individual countries and the WHO have to beg for money when outbreaks happen, and this takes time and costs lives.

We need action at the global level, too. International institutions are in desperate need of reform. WHO has proven itself incapable of leading the charge, whether for its financial troubles or bureaucratic processes, and no other actor has stepped up to lead either.

If you are scared of Ebola, it's only the beginning. The failure to fight this epidemic in a timely manner is not just the fault of indifference or laziness or an impotent WHO; it's a well-known systems failure. Poorly coordinated outbreak responses aren't a new problem and they'll probably arise with every future epidemic.

Ebola won't be the plague that wipes us out, but there will be future outbreaks and we will have watched them coming, meticulously documented their potential in one journal and newspaper article after another, and done nothing about their fundamental root causes to stop them.

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