Finally, Straight Talk On Ebola: It Is About to Get Worse. Much Worse

Far too many leaders, organizations and agencies still don’t understand the concept of virus time or the desperate need for command and control leadership in the affected countries.

 

(Editor’s Note: There is a palpable sense of unreality and delusion in most official pronouncements and promises about the bubbling Ebola epidemic. If ever there was a time for straight talk and fast, well directed action by government and health officials this is the time. Most of what I have heard from the Center for Disease Control and other federal officials rings as unrealistic as it is hollow. This article and the video below is the first thing I’ve seen that makes sense. — Mark L. Taylor)

By Michael T. Osterholm
Politico (9/3/0/14)

We know how the disease will likely spread in the months ahead. Each year, thousands of young West African men and boys are part of a migratory work population not too dissimilar from U.S. migrant farm workers. Crop-friendly rains wash over West Africa from May to October, forming the growing season. These young men typically help with harvesting in their home villages from August to early October, but afterward head off for temporary jobs in artisanal gold mines in Burkina Faso, Mali, Niger and Ghana; cocoa nut and palm oil plantations in Ghana and Cote d’Ivoire; palm date harvesting and fishing in Mauritania and Senegal; and illicit charcoal production in Senegal, Mali, Cote d’Ivoire, Ghana, Burkina Faso and Niger.

This migration is about to begin, even for young men whose villages have been recently hit by EVD. These workers find daily laborer jobs at $5 per day, half of which they remit to their families back home. Like their ancestors before them, they use little-known routes and layovers through forests to avoid frontier checkpoints. They usually have ECOWAS ID cards, providing free passage to all the member states of the Economic Community of West Africa States. It takes one to three days to travel from the EVD-affected countries to these work destinations. There is no need for Ebola to hop a ride on an airplane to move across Africa: It can travel by foot.

We need a Plan B

Densely populated African cities such as Dakar, Abidjan, Lagos and Kinshasa—teeming with jam-packed slums as far as the eye can see—could be most at risk. This is the nightmare scenario. It is all too real, and yet no international, coordinated plan exists for how to respond to what would likely be an even more catastrophic event. Ask the world’s intelligence and security experts what an Ebola epidemic unleashed on Africa’s megacities could mean for the continent’s stability. We need a Plan B, or hundreds of thousands of people may die.

And what of Plan C? The use of effective, safe vaccines has been a foundation of modern public health. We even eradicated one of the Lion Kings of infectious diseasesmallpoxwith an effective vaccine. Unfortunately, not all infectious agents can be relegated to the history books through vaccination. We are still searching for effective and safe vaccines for diseases such as AIDS, malaria and TB. But I feel certain that a safe and effective Ebola vaccine is on it way.

Will it come soon enough? On virus time? And on the scale that the disease demands? Only a month ago, the primary discussion around developing, approving, manufacturing and distributing an effective and safe Ebola vaccine was to protect a few thousand health-care workers and prevent the few remaining community-acquired Ebola cases that continued to occur. But it’s now a different ballgame. This epidemic could grow much, much larger and become what we call an endemic diseaseone that doesn’t go away. Science recently published two must-read articles, by Jon Cohen and Kai Kupferschmidt, about the grim reality of trying to find and produce an effective vaccine: Their conclusion was that government bureaucracy, a lack of adequate funding and battles between government and private-sector companies have prevented progress.

Black Swan scenario

The first critical mistake public-health officials often make amid such outbreaks is failing to consider another black-swan scenario. At the moment, they are focused only on meeting the vaccine need in the three affected countries. If this virus makes it to the slums of other cities, the epidemic to date will just be an opening chapter. Africa contains more than a billion people, and is growing faster than anywhere else in the world. If world leaders don’t make it a priority now to secure up to 500 million doses of an effective Ebola virus vaccine, we may live to regret our inaction. It’s that serious.

Securing 500 million doses of an effective Ebola virus vaccine is going to require a partnership between government and vaccine manufacturers that puts it on the same footing as our response to an emerging global influenza pandemic. This will require mobilizing people and resources on a massive scale—it has to be the international community’s top priority.

In the words of Sir Winston Churchill, “It’s no use saying, ‘We’re doing our best.’ You have got to succeed in doing what is necessary.” It’s time to do what is necessary to stop Ebola. Now.

Bureaucracy time vs virus time

Plan A continues to fail today for one simple reason. Donor countries and organizations are operating on “program or bureaucracy time,” while the epidemic is unfolding on “virus time.” Thirty days of planning to deliver on-the-ground support might be considered lightning speed to a foreign aid officer, but it is an eternity for a virus being transmitted by physical contact between many people living in intensely crowded conditions. Each day of delay is also another day of hell for newly infected Ebola patients and their exhausted health-care providers.

Think of fighting a forest fire. Imagine waiting days before the necessary resources arrive; it means the blaze has expanded by the hour. And stopping a 100-acre fire is a lot different than containing a 100,000-acre fire. Every day the global response to Ebola falls far short in terms of treatment beds, health-care providers, public health workers and even adequate food and safe water is another day the epidemic grows substantially and becomes that much harder to contain. What might have been an adequate response last month now becomes much less effective.

We’ve seen increased finger-pointing about who didn’t and still hasn’t provided critical leadership or necessary resources. This debate will play out for years to come. But no one individual or group of individuals is to blame; instead, almost everyone involved is. And, unfortunately, far too many leaders, organizations and agencies still don’t understand the concept of virus time or the desperate need for command and control leadership in the affected countries.

Imagine if the only plan for Minneapolis to respond to a rapidly spreading fire were to call the New York City fire department for mutual aid. Leaders in both cities would speak proudly of the caravan of fire trucks and firefighters making their way westward. In the meantime, downtown Minneapolis would quickly become an inferno. That’s essentially the international response to the West African Ebola epidemic. World leaders have never prepared themselves or the global community for the public health actions necessary to combat this type of situation.

Igniting gasoline

Doctors Without Borders and other NGOs on the front lines tried to warn the public health community as early as March that this Ebola outbreak was very different and would require unprecedented response resources. No one listened then, and the virus continued to spread unfettered across the three countries. Once it got a foothold in crowded, poverty-stricken West African cities, it was like igniting gasoline.

The U.S. government has in recent days taken a leadership role in responding to this international crisis. President Obama has urged a comprehensive, rapid response. His willingness to deploy military troops to support critical transportation, logistics and supply chain needs is an important step. (But again, the president’s promises of a month ago have been slow to become reality, and in many instances have not yet been acted upon.) CDC Director Dr. Tom Frieden has issued clear and compelling warnings over the last six weeks about the dire consequences of our ineffective response. CDC professionals are also providing valuable support in trying to track and stop new cases.

But the international public health community had never seriously planned for a “black swan” event such as this epidemic, so having an alternative to Plan A was never considered. You might call the recent quarantine restrictions employed by the governments of Liberia and Sierra Leone as an attempt at Plan B. But these measures have largely failed to control the disease’s spread, while they have been a humanitarian disaster.

For the affected countries, sadly, it’s already too late for a Plan B. Regardless of whose case estimates you believe, those put forward by the WHO or the worst-case numbers put forward by the CDC, the number of cases in these countries will increase substantially in the coming months. Everything in my 40 years of experience as a public health official and infectious disease researcher tells me this virus has a high likelihood of spreading to other African countries. And unlike in Nigeria and Senegal, it might not be so easily contained this time. What is our plan to fight this Ebola war on multiple African fronts when we can’t handle the current battles in West Africa?

The coming months

We know how the disease will likely spread in the months ahead. Each year, thousands of young West African men and boys are part of a migratory work population not too dissimilar from U.S. migrant farm workers. Crop-friendly rains wash over West Africa from May to October, forming the growing season. These young men typically help with harvesting in their home villages from August to early October, but afterward head off for temporary jobs in artisanal gold mines in Burkina Faso, Mali, Niger and Ghana; cocoa nut and palm oil plantations in Ghana and Cote d’Ivoire; palm date harvesting and fishing in Mauritania and Senegal; and illicit charcoal production in Senegal, Mali, Cote d’Ivoire, Ghana, Burkina Faso and Niger.

This migration is about to begin, even for young men whose villages have been recently hit by EVD. These workers find daily laborer jobs at $5 per day, half of which they remit to their families back home. Like their ancestors before them, they use little-known routes and layovers through forests to avoid frontier checkpoints. They usually have ECOWAS ID cards, providing free passage to all the member states of the Economic Community of West Africa States. It takes one to three days to travel from the EVD-affected countries to these work destinations. There is no need for Ebola to hop a ride on an airplane to move across Africa: It can travel by foot.

The nightmare scenario

Densely populated African cities such as Dakar, Abidjan, Lagos and Kinshasa—teeming with jam-packed slums as far as the eye can see—could be most at risk. This is the nightmare scenario. It is all too real, and yet no international, coordinated plan exists for how to respond to what would likely be an even more catastrophic event. Ask the world’s intelligence and security experts what an Ebola epidemic unleashed on Africa’s megacities could mean for the continent’s stability. We need a Plan B, or hundreds of thousands of people may die.

And what of Plan C? The use of effective, safe vaccines has been a foundation of modern public health. We even eradicated one of the Lion Kings of infectious diseasesmallpoxwith an effective vaccine. Unfortunately, not all infectious agents can be relegated to the history books through vaccination. We are still searching for effective and safe vaccines for diseases such as AIDS, malaria and TB. But I feel certain that a safe and effective Ebola vaccine is on it way.

Will it come soon enough? On virus time? And on the scale that the disease demands? Only a month ago, the primary discussion around developing, approving, manufacturing and distributing an effective and safe Ebola vaccine was to protect a few thousand health-care workers and prevent the few remaining community-acquired Ebola cases that continued to occur. But it’s now a different ballgame. This epidemic could grow much, much larger and become what we call an endemic diseaseone that doesn’t go away. Science recently published two must-read articles, by Jon Cohen and Kai Kupferschmidt, about the grim reality of trying to find and produce an effective vaccine: Their conclusion was that government bureaucracy, a lack of adequate funding and battles between government and private-sector companies have prevented progress.

500 million doses

The first critical mistake public-health officials often make amid such outbreaks is failing to consider another black-swan scenario. At the moment, they are focused only on meeting the vaccine need in the three affected countries. If this virus makes it to the slums of other cities, the epidemic to date will just be an opening chapter. Africa contains more than a billion people, and is growing faster than anywhere else in the world. If world leaders don’t make it a priority now to secure up to 500 million doses of an effective Ebola virus vaccine, we may live to regret our inaction. It’s that serious.

Securing 500 million doses of an effective Ebola virus vaccine is going to require a partnership between government and vaccine manufacturers that puts it on the same footing as our response to an emerging global influenza pandemic. This will require mobilizing people and resources on a massive scale—it has to be the international community’s top priority.

In the words of Sir Winston Churchill, “It’s no use saying, ‘We’re doing our best.’ You have got to succeed in doing what is necessary.” It’s time to do what is necessary to stop Ebola. Now.

(Michael T. Osterholm is director of the Center for Infectious Disease Research and Policy at the University of Minnesota.)

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