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10/14/2014

Why we ignored Ebola until recently

by Craig Klugman, Ph.D.

Ebola burst onto the scene in 1976 when a thirty-old man arrived at the Yambuku Mission Hospital in Zaire complaining of severe diarrhea. He left the hospital two days afterwards and was never found again. In the days and weeks that followed, people who were patients or care providers at this facility when he was there all died after experiencing dehydration, fever, vomiting, diarrhea, and bleeding everywhere. The death rate was staggering, as over 80% of affected patients did not recover.

Since then, the CDC reports there have been 34 distinct outbreaks of the five strains of Ebola. Two strains do not infect humans. Epidemics have caused human deaths in Zaire, Sudan, Ivory Coast, Gabon, Congo, and Uganda. The latest outbreak began in March 2014 and has affected large swaths of Guinea, Liberia and Sierra Leone with more limited transmission in Nigeria, Madrid, and Dallas. Senegal has also reported a travel-associated case. The CDC estimates that there have been 8,400 cases of Ebola as of October 10 (4,656 are confirmed by lab tests) and 4,033 deaths.

Given that the world has known about the disease for 40 years, why is it only now that it has been getting such widespread attention and panic? The reason is that the disease is finally being seen as a risk to the developed world. When it was confined to a few hundred cases in remote regions among poor people, the West as a whole did not worry. The developed world did not devote adequate funding to finding the natural host (believed to be fruit bats, but not definitive), to develop treatments, or to create a vaccine. Compared to the number of people killed by flu, HIV, the wars on terror, and gunshots, Ebola is an orphan disease—one that affects too few people to be a commercially viable market. In other words, no one will make enough money from drugs for the disease to make it worthwhile to do research on them.

Like most people in bioethics, I have received interview requests from reporters about the current Ebola epidemic. My university even sent out a press release letting news outlets knows what resident expertise was available for their reports. As someone who works in public health ethics, one question that I am consistently asked is “How can we protect ourselves?” The reporter makes it clear that I’m expected to talk about ceasing flights to west Africa, airport screening of international visitors (my spouse works in a hospital that is now designated for receiving flyers into O’Hare International suspected of having Ebola), screenings in hospitals (a friend who had surgery this week in the heartland went through such a screening on admission), quarantining physicians returning from Liberia who violate their isolation orders, and increased training in use of protective equipment. The most recent issue is whether hospitals should have unilateral DNR policies for anyone with Ebola. Reporters have been universally surprised by my response, “We have to go to Africa and stop the epidemic there.”

All human outbreaks of Ebola have begun in Western Africa. This is a part of the world with very limited health care resources—few health care providers, few hospital beds, and few supplies. One recent Ebola patient in the U.S. required 10 liters of replacement fluid a day. That much IV replacement fluid is not available in these regions. Even if personal protective equipment were available, the materials to clean them thoroughly are lacking and training in their proper use is absent. The recent Dallas nurse who came down with Ebola because of an innocent breach in protocol shows just how challenging and difficult appropriate measures are.

There also are not enough hospital beds, and not enough isolation units. This is partly why the U.S. military is in Liberia building hospitals.

In the U.S. and the developed world, our complacency toward Ebola has been a result of privilege—we have not had to worry about this disease of poverty, of Africa. It has been “over there” and not been a real threat in the homeland. With Ebola migrating to the major cities and increasing economic ties with this part of the world, Ebola is not an African issue, it is a global health crisis. The mission to save lives can only be won by providing needed medical support services in Africa. Screening at the borders are doomed to failure because they are inexact and the disease has a long latency period. Such efforts also risk stigmatizing people from these countries who are healthy and virus free. Viruses do not have passports. They do not acknowledge lines on a map. And they do not care how much money anyone has in the bank.

Dr. Margaret Chan, the director general of the World Health Organization says that Ebola threatens not only the health of large populations, but poses a threat to the security and civil well-being of countries dealing with the scourge. Protecting ourselves means helping out in Africa. It means bringing not only care providers but also supplies and equipment. It means helping to build an infrastructure so that when the epidemic passes, there remains a vibrant health care system that can deal with the next outbreak and the one after that. In a global environment, it takes a world to care for a village. And that’s how can we help deal with Ebola.

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