Ebola: What went wrong?

The current Ebola crisis has claimed over ten thousand lives in West Africa, and continues to cause hundreds of new infections every week. Yet, media coverage of the crisis had been meager up until the summer of 2014, an entire half-year after the start of the outbreak in late 2013. The world’s delayed reaction has generated criticism for both public ignorance and for lackluster government response. But where did we go wrong? What could we have done differently that may have changed the course of this epidemic?

To get a better understanding of these difficult questions, we spoke with Princeton University’s Adel Mahmoud, a professor in both The Woodrow Wilson School of Public and International Affairs and The Department of Molecular Biology. Professor Mahmoud’s research focuses on the causes and emergence of infectious diseases, as well as the discovery, development, and global deployment and use of vaccines.

Question: What was the biggest shortcoming of the US and West African governments’ response to the Ebola crisis?

Answer: We were coming from behind in the response. This is a virus that we have known to exist since 1976. We know that it happens in outbreaks. We know that when it happens, the immediate need is for facilities to take care of patients and to deliver healthcare in a way whereby you don’t infect healthcare workers. The knowledge of how to deal with the issue is not rocket science, and it’s not new.

Late in 2013, when the outbreak first started, we should have immediately been pursuing identification, isolation, barrier nursing—and we could have influenced the course of events. In some ways that’s not very helpful because it’s historical. Now, when we are in the middle of the dilemma, the US says we’re going to send a few hundred of our troops, and we’re going to build facilities to take care of patients. That’s very well and good. The problem is, these things take time. And in the meantime, the infection is progressing, and the transmission is happening.

It would be unfair to ask “why didn’t [West African governments] respond better?” We today are facing a very serious challenge because most of the resources, most of the attention is going towards Ebola now, but what about all the other diseases that are there? What are you going to do with the polio campaign? What are you going to do with the immunization campaign? The resources are very limited, and there is no question today—there is a shift to put it for Ebola. The depth of resources and the depth of capabilities is very thin. You suck it in one direction, you lose it in other direction.

Question: In retrospect, what could the world have done differently to diminish the extent of the Ebola crisis?

Answer: There are a few things that would have changed the nature of what we have seen in West Africa. For example, we have been working on candidate vaccines for Ebola for the last fifteen to twenty years. Rather than working on a candidate, testing it in a couple of experimental animals, and throwing it in the freezer, what we should have done is to take these vaccine candidates, examine which is the best, take them through phase I, and take them through phase II, so you know you have an effective vaccine in the freezer. You face an outbreak like this, then you only have two steps: scale up, and deploy. What we’re doing today is, taking candidates from the lab, going through phase I, and then phase II, and only then would we be able to scale up and deploy. You really have to invest some effort in getting ready. And getting ready does not mean you spend billions and billions making things that nobody would use. No—getting ready means that you have explorations, and you have the first couple of steps to put you in a much more capable position to respond. Have a candidate drug available. That’s the difference.

Question: The CDC has set recommendations that individuals who have been potentially exposed to Ebola be monitored for twenty-one days, but not quarantined. A few states in the US, such as New Jersey and Connecticut, have ignored these guidelines by instating mandatory quarantines anyways. In fact, this issue has been contested in Maine’s district courts, which ruled against the mandatory quarantines. Do quarantines here in the US serve a real public health benefit, or are these states just acting out of fear?

Answer: The difficulty in answering this question is related to assessing the risk of someone coming from an Ebola-infected area. What is the risk that that individual would have the infection? That’s the first serious question you have the answer. And if the risk is high, then I would say quarantine is a reasonable approach; for example, a healthcare worker who was delivering care to Ebola patients in a West African country. In quarantine we’re not asking people to be put in jail, we’re just saying: stay home for twenty-one days. For the sake of public health safety, that is not an undue burden. But if the exposure is marginal, or if the contact is marginal, then monitoring temperature for the twenty-one days is a reasonable approach. When you are in the heat of the battle and people are just yelling and screaming at each other, logic gets lost. The issue here is very simple: assess the risk, and if the risk is reasonable, then put the person in isolation.

Question: In many West African countries, there is a very negative image of Public Health workers. Many families are reluctant to hand their loved ones over to be transported to hospitals because it is seen as a death sentence. How can Public Health Policy be used to address these social issues to change public perception of the disease?

Answer: When you have a village in West Africa, and several people drop dead, and then you have a team descend upon them in moon suits—what do you expect? You are injecting fear, immediately. Ebola happened in countries where they have known Ebola, and it has been around, in and out, for some time. But as long as it is not the disease of the day, no one wants to talk about it. So we lost ground, the ground of public education, of information, of dissemination, of trust. Those are the issues that make people part of the solution. People are not the enemy here!

What we have to consider is a campaign of education, of context, of information dissemination, by local people who are trusted in the community. Explaining, what are these moon suits? How is this disease transmitted? What is Ebola? Unfortunately, when you are in the heat of the battle and you have thousands of people in West Africa dying—that element gets forgotten. But it needs to be brought back on the forefront. These are countries with suspicion about the health profession, with suspicion about Western medicine, with suspicion about vaccines. We can’t just say “we’re going to build a hospital, and we’re going to put you in quarantine, and we’re going to do this and that.” You need real human interaction at a very personal level.

Question: Senegal and Nigeria have successfully contained and ended their outbreaks of Ebola. Is this success a reflection of proper public health response, and if so, which ones?

Answer: In some ways, you have to say yes. Obviously, they did not face a major outbreak—but they managed to control it by, basically, quarantining all the patients and their contacts. It’s all about the proper isolation, and the proper care. And the proper care today is not specific therapies; the proper care is fluids, electrolytes, and maintaining body function, which we physicians learned how to do years back. It’s an issue of getting these well-known techniques of medical treatment deployed.

Question: How much responsibility should the US take in fighting Ebola in affected West African Nations? What would be the best way to help?

Answer: The best thing that the US can offer is scientific know-how. The current front candidates for Ebola vaccines all came from the US. I would have liked to have seen them partially developed earlier, but the first thing that the US can offer, is scientific input. The second is exactly what President Obama did, which is to deploy humanitarian support in situations where it is urgently needed. There aren’t many other countries that can match what the US can do in this regard. The third element is financial support. I think we are doing all three.

Question: How significant of a role have NGOs such as Doctors without Borders (MSF) played in containing Ebola?

Answer: They are an essential element of the response. Developing countries have a very complicated agenda to face the future and—don’t take this as an insult or as a criticism—their ability to spend on the infrastructure for health is limited. So when something like [Ebola] comes up, it taxes the total capability of these countries. They can’t do it their own! They need support from abroad.
Private, non-profit organizations have the ability to move quickly. The edge of advantage of MSF is that they can deploy doctors tomorrow. That’s phenomenally important.

Question: What can we learn from the Ebola epidemic when addressing future public health crises?

Answer: There are quite a few lessons. One of them is that the threat of microbes to the human population is a constant feature of life on earth. If it is not Ebola, it will be something else. We have no other alternative but to learn how to predict, and how to get ready, and how to respond. It’s one thing to have noticed that Ebola has started—that was the end of 2013. It’s another to try to face it in the middle of 2014. Where have we been?

Second, what elements of response do you have? You should have had some ideas of vaccines, some ideas of drugs beforehand. Most of these infections are going to emerge in areas that are not 100% prepared to deal with it. The world has to be prepared to respond, and Ebola showed that the world was not. The virus was running around amok in Guinea in 2013, and no one talked about it. We started waking up in the middle of 2014. Come on guys, where have you been? The world was caught unprepared.