By Richard Knox
At the memorial service last weekend for the only person to have died of Ebola on American soil, the Liberian clergyman who eulogized his countryman Thomas Eric Duncan posed a question we all should be thinking hard about right now.
“Where did Ebola come from to destroy people — to set behind people who were already behind?” Methodist Bishop Arthur F. Kulah wondered.
Here’s the reality: Until the world (and especially the United States of America) refocus on the “people who were already behind” in this battle of virus-versus-humanity, no one can rest easy.
Ebola is an animal virus that has sporadically caused local human outbreaks in Africa for at least 38 years. But now it has crossed into people who live in densely populated African nations with barely functioning health systems and daily jet connections to the rest of the planet.
"It’s like you’re in your room and the house is on fire, and your approach is to put wet towels under the door."World Bank chief Jim Yong Kim
This is entirely predictable, as scientists who watch emerging diseases have long known. They just didn’t know which virus would be the next to terrorize the world. (SARS and HIV showed how it can happen, remember?)
Those of us who, like me, report on global public health have a sense of inevitability as we watch the Ebola crisis unfold. We always knew it would mostly affect, as Bishop Kulah so aptly puts it, “people who were already behind.”
And we knew the people least affected by this scourge — privileged denizens of wealthier countries — would overreact out of misplaced fear for themselves, rather than a reasoned and compassionate understanding about what needs to be done.
So we see the freaked-out, wall-to-wall, feedback-loop media coverage we’re experiencing now. Schools closing down in Ohio for completely unnecessary disinfection. Recriminations against hapless health workers who suddenly find themselves dealing with an exotic new threat.
Politicians demanding to seal off the Mexican border to prevent Hamas terrorists from deliberately bringing Ebola into the Homeland. (Thanks, Congressman Joe Wilson of South Carolina, I’ll bet Hamas masterminds hadn’t even thought of that.) You can expect more of the same in coming weeks.
All this when the focus urgently needs to be on the real Ebola victims in Liberia, Sierra Leone and Guinea.
Let’s rewind the tape a little bit. Researchers predicted that Ebola would begin to show up in the U.S. and Europe by the end of September, based on analysis of burgeoning cases in West Africa and air traffic patterns. As events have proven, they were right on target.
The contemporary world is a porous place. It’s a fact.
U.S. public health officials knew that. And, to their credit, they began preparing for the arrival of an Ebola-infected person on our shores in the summer.
It’s not an easy thing to plan for. Where might he/she pop up — New York, Boston, Minneapolis, Dallas? What would he/she look like? Where would he/she first seek care for symptoms that mimic a hundred different disorders? Which health workers should be trained, and how, to minimize the risk of spread?
When I interviewed Boston public health and medical authorities for CommonHealth last month, I was struck by several things:
•They were taking the threat seriously.
•They were confident they could deal with it — perhaps overconfident.
•They thought (or some of them did) that a case of Ebola in Boston could be managed without much public alarm.
Fat chance, I thought.
Getting the public health messaging right is one of the trickiest aspects of the drama. People understandably have a hard time wrapping their minds around a rapidly lethal virus that’s very contagious — but only after people are showing symptoms, and only if those around them are exposed in certain ways. We simply don’t have experience with threats like this.
And Americans, who by and large lead remarkably low-risk lives by the standards of much of the world, paradoxically have very little tolerance for risk. Their anger quickly flares at authorities who they think have failed to protect them from any perceived threat.
Alas, the current Ebola crisis has shown that public health authorities whose job is to protect us from these threats were, charitably speaking, unequal to the task.
The World Health Organization has been the most distressing disappointment.
The WHO used to have a crackerjack team of infectious disease specialists who were constantly scanning the horizon for new infectious disease threats, and a staff of technical experts ready to parachute into outbreak zones to contain the danger. Now we know that budget cutbacks have decimated the WHO’s ability to respond to this very sort of crisis.
WHO Director General Margaret Chan told the head of Doctors Without Borders in early September that “it was a fantasy…to think of the WHO as a first responder ready to lead the fight against deadly outbreaks around the world,” according to the New York Times.
In other words, the world’s frontline defense against new disease threats is a paper tiger.
Just this past week, we learned that the WHO acknowledges (at least internally) that it botched its response to Ebola. A big reason, reportedly, is that Chan, the titular WHO leader in Geneva, has no control over the WHO’s regional director in Africa, a political appointee who does not report to her.
According to the internal WHO report, the WHO regional director for Africa, Dr. Luis Sambo, failed to alert Geneva to Ebola’s spread last summer.
“They didn’t do anything,” Dr. Peter Piot, director of the London School of Hygiene and Tropical Medicine and the co-discoverer of the Ebola virus, told Maria Cheng of the Associated Press (a former WHO public affairs official). “That office is really not competent.”
In this country, current ire is focused on the U.S. Centers for Disease Control and Prevention and the Obama administration for missteps in handling the first imported case of Ebola — Liberian Thomas Eric Duncan — and failing to prevent at least two Dallas nurses who cared for him from getting infected and exposing others.
It appears that the CDC over-relied on local hospital and public health officials to deal with a virus never before seen on these shores except in the highest-containment laboratories.
That over-reliance reflects CDC’s rigid culture. The agency has always insisted on deferring to state and local health authorities. Under U.S. law, they traditionally have primary responsibility for public health. The CDC acts in an advisory role — and waits to be invited in by local authorities. Clearly, that’s not the best way to deal with an unfamiliar and fast-moving global disease threat.
The CDC implicitly acknowledged as much last week when it said it would henceforth be more hands-on in coping with Ebola — sending in a SWAT team of infection-control experts to bolster the ability of a hospital and local health agency to cope.
That leaves unanswered a disturbing aspect of the Dallas episode that helped put the nation into a state of high anxiety. When Mr. Duncan first showed up at Texas Health Presbyterian Hospital in Dallas with a fever and a recent travel history to Liberia, he was sent home with an antibiotic.
It makes you wonder whether the institution, which has been characterized as the upper crust of Dallas hospitals, saw Mr. Duncan as just another black patient with unspecific symptoms and no private doctor to tend to him.
And that brings us back to Bishop Kulah’s observation that Ebola “set(s) behind people who are already behind.”
So far the world has been shockingly indifferent to the plight of West Africans who are bearing the brunt of this terrible disease. The United Nations has received just $377 million of the $1 billion it says it needs to begin to bring the burgeoning West African epidemic under control. Delay will surely increase that price tag.
Turning our backs on the problem won’t work. Dr. Jim Yong Kim, head of the World Bank, who has a deep background in public health, offers a compelling counter-argument to those who say the U.S. should just close its borders to those coming from Ebola-affected countries.
“It’s like you’re in your room and the house is on fire, and your approach is to put wet towels under the door,” Kim told NPR’s Steve Inskeep. “That might work for awhile, but unless you put the fire out, you’re still in trouble.”