Ebola and the global response to an epidemic

One year has passed since the declaration of what has become the largest Ebola outbreak in history, with more than 10,000 deaths. The virus escaped control as countries and global agencies failed to acknowledge and contend with the magnitude of its spread.

Treatment centres were overwhelmed. Sick people died on city streets, and new cases multiplied inside health care facilities, killing a significant proportion of the already inadequate health workforce in the three most affected countries, Liberia, Sierra Leone and Guinea.

However, after two US aid workers and a traveller to Nigeria fell ill last summer, setting off a panic, a massive global initiative to combat Ebola swung into place. The effort has been messy, inefficient and expensive, often lagging the epidemic's twists in tragic ways.

But the effort has also established expertise that may be built upon to prevent similar tragedies in the future - and shown personal and institutional bravery.

"None of us have ever been involved in anything of this magnitude, complexity and potential severity before," said Dr David Nabarro, the United Nations special envoy for Ebola.

“There’s a huge process of analysis and lesson learning underway.”

The African Union (CDC) for the first time sent hundreds of health personnel to confront a medical crisis even as the logistics of their arrival were rocky.

The US Centres for Disease Control and Prevention worked with multinational teams led by the World Health Organisation (WHO) in more than a dozen unaffected African countries to help prevent the disease from spreading further.

It was part of the largest international deployment in the CDC’s nearly 70-year history, supported by a US congressional appropriation of more than $1 billion (€920 million) made available for the larger American response.

Despite difficulty filling positions, the WHO now reports that it has more than 700 people working at 77 field sites, the largest emergency response in its history.

Charities with no background treating Ebola patients began running hospitals specialised for Ebola care. Some were built by militaries and others staffed by hundreds of personnel from China and Cuba who were also facing Ebola for the first time and trying to overcome language challenges.

The affected countries established strong crisis teams and mobilised thousands of health workers, grave diggers and student outreach teams to fight the disease.

They worked in dangerous conditions, often without pay. They were sometimes shunned by their families and, unlike many foreign workers, without the option of medical evacuation to Western countries.

‘Extraordinary action’

“The level of resourcefulness and dedication shown by Sierra Leoneans involved in the front lines is the most extraordinary civic mobilisation action I’ve ever seen in my country,” said OB Sisay, director of the situation room at the National Ebola Response Centre in Freetown, which formerly housed a special war crimes court.

“To some extent that has helped cement a sense of nationhood here.”

Throughout most of the crisis, experimental Ebola treatments and vaccines were offered almost exclusively to international aid workers; now scientists are testing them in Africa under accelerated research protocols that include regulatory and ethical approval in the affected countries and abroad.

UN secretary-general Ban Ki-moon established the United Nations Mission for Ebola Emergency Response, its first international mission devoted to public health, though it has been widely criticised as being lumbering, expensive and unfocused.

Still, the global effort has not yet eliminated the epidemic. The combined number of new cases each week in Guinea and Sierra Leone has flatlined for months in the 100-to-200 range, consonant with the largest historical outbreaks. On Friday, Liberia announced its first positive Ebola test in three weeks.

Aid workers, meanwhile, are scrambling to deal with violent resistance to Ebola treatment and safe burials. Responders are questioning whether, in a rush to improve technical assistance, they gave short shrift to understanding societal dynamics.

Most importantly, perhaps, Ebola has laid bare the inadequacy of current global mechanisms for detecting outbreaks and quickly mobilising a response.

“We need something more robust than an ad hoc system that we set up halfway through it,” said Dr Bruce Aylward, who leads Ebola response efforts for the WHO, which has come under particular criticism.

Reforms have been proposed, but agencies have been slow to acknowledge their mistakes publicly and reckon with them, decreasing the chances that change will occur.

Instead, the agencies are pointing fingers at one another. Médecins Sans Frontières (MSF), practically the only private charity with specialised Ebola treatment experience before the epidemic, provided most of the medical aid in the early months. Overwhelmed, it called repeatedly for global action.

Governmental failure

In a report looking back over the year, MSF assailed the US and other governments for failing, among other things, to send specialised biohazard response units to treat patients.

“We considered the only organisations in the world that might have the means to fill the gap immediately might be military units with some level of biological warfare expertise,” Christopher Stokes, general director of MSF, is quoted as saying in the report.

Dr Joanne Liu, MSF’s international president, said: “US helicopters would not even transport laboratory samples or healthy personnel returning from treating patients.”

Jeremy Konyndyk, director of the Office of Foreign Disaster Assistance at the US Agency for International Development, said in an interview that those criticisms reflected a misunderstanding of the US military’s capabilities.

“There was a perception among MSF and more broadly that surely somewhere in the Pentagon there must be some rapid biohazard response team that could go and do this,” Mr Konyndyk said. “That just wasn’t the case.”

Instead, at the urging of Mr Konyndyk and others, charities and the US public health service agreed to operate treatment units that the US military and others would build and the US government would fund.

Other governments, including the British, French and Chinese, also helped build and support treatment units, run by a range of international agencies, and the World Bank made hundreds of millions of dollars available.

The number of new infections had declined sharply in Liberia by the time many of the US-sponsored treatment centres were set up, but Mr Konyndyk said systems for safe burials, improved laboratory capacity, distribution of protective gear and supplies and social mobilisation within communities had made a difference.

“The interventions that were easy to scale rapidly had a pretty significant impact.”

Most successful, perhaps, was the prevention of the epidemic from spreading more widely. When Ebola reached Mali, Nigeria and Senegal, it was quickly stopped there.

“It wasn’t that they were well prepared, because they weren’t, but they were a bit prepared, and that made a difference,” said Mr Aylward.

The challenge now is to determine “what part of the bit of the preparedness they had in place paid such a huge dividend, and how do you take advantage of that.”

New York Times