An ambulance at the residence of the nurse in Spain who contracted Ebola (Image: Reuters/Susana Vera)

After the first cases of Ebola in Europe and the US, how well prepared are nations beyond western Africa to cope with the virus, asks Debora MacKenzie

Ebola is spreading. Thomas Eric Duncan, the Liberian who carried Ebola to the US, has died. Teresa Romero, a Spanish nurse who caught Ebola while treating a returned missionary, is getting worse. In Australia, a nurse just back from Sierra Leone has been quarantined with fever. In the coming weeks and months, there will be many more people inadvertently carrying Ebola from the heart of the epidemic in West Africa into countries rich and poor.

What will happen? In poor countries, cash-strapped health services will struggle to limit the contagion, and the virus could spread further. In rich countries, health officials insist there is little risk. But they could still be in for a rough ride.


Certainly the biggest impact will be in poorer countries. Besides those neighbouring the African epidemic, models put Morocco, South Africa, Lebanon, Kenya and China at highest risk.

Spiralling cost

Nigeria ended the chain of infection connected to one Liberian man who brought Ebola into the country in September. But to find the 20 people subsequently infected required 18,500 visits to monitor 900 people quarantined after coming into contact with infected people, and cost $30 million. Nigerian officials privately say the country cannot afford many more like that.

Yet more cases are likely, because the borders of the three most affected countries, Liberia, Sierra Leone and Guinea, are unlikely to be closed. The World Bank says this is to protect their struggling economies. But Anthony Fauci, head of the US National Institute for Allergy and Infectious Disease, revealed another worry this week by saying that “governments could fall if you just isolate them completely“. Such civil collapse would make fighting the epidemic virtually impossible.

Epidemic models make France, the US, Britain and Belgium the most likely rich countries to see cases. “America has the best doctors and public health infrastructure in the world and we are prepared to respond,” insists the US federal Department of Health and Human Services.

“Sporadic cases of Ebola virus disease in Europe are unavoidable,” said Zsuzsanna Jakab, European director for the World Health Organization (WHO). “However, the risk of spread of Ebola in Europe is avoidable and extremely low. European countries are among the best prepared in the world to respond.”

Health cuts

Yet “controlling Ebola won’t be easy and it won’t be cheap”, says Peter Smith of the London School of Hygiene and Tropical Medicine. It will also involve a steep learning curve. Despite warnings, Spanish and US hospitals let their recent cases stay in the community while infectious. The Spanish nurse notified her hospital when she developed fever but was told to take aspirin. Isolating and treating Duncan in the US is estimated to have cost $500,000. Tracking his contacts will cost still more.

Health systems in many parts of Europe have been hit by austerity measures put in place after the 2007 financial crisis. “In some countries, governments are withdrawing from their responsibility for ensuring the health of their people,” warns Martin McKee of the London School of Hygiene and Tropical Medicine. “Ebola, whether in West Africa, Texas or Spain, has reminded us that effective health systems are at least as important for a country’s national security as well-equipped armed forces.”

McKee and his colleagues report that Spain cut its health budget nearly 14 per cent in 2010, and further last year, with public health expenditure down 45 per cent. Spanish medics complained of poor protective equipment after news of Romero’s infection; the doctor treating her reports that his gown was too small and left skin exposed.

The UK is estimated to have a 50 per cent chance of admitting someone with Ebola before the end of October. Four hospitals there are designated for isolating cases, but only one is so far equipped. State-funded health staff will have to spot and isolate suspected cases despite pressure to cut spending, and despite the likely flood of patients with fever, nausea and vomiting, which are early symptoms of both Ebola and common, less serious viruses.

Screening flights

This week the US, UK and Canada said they would screen arrivals for fever at major airports. But that could give a false sense of security, says Isabelle Nuttall of the WHO. People can travel during the 21 days the virus can take to produce symptoms, and early fevers yield to aspirin, so cases are likely to be missed. Duncan did not have fever on arrival in the US.

And Ebola carriers might not arrive by air. General John Kelly of the US Southern Command, which oversees US military operations in South and Central America, warned this week that if Ebola epidemics break out in that region, people may run for the US.

Already, he says, many West Africans are smuggled overland into the US. He describes illegal Liberians in Costa Rica who “could have made it to New York City and still be within the incubation period for Ebola” from the time they left Liberia.

Equipment shortages

The ability of affected nations to isolate patients will also depend on equipment being available. The 2003 SARS epidemic was quelled with the same approach: isolate primary cases, quarantine their contacts and isolate those that become sick.

There were just over 8000 cases of SARS worldwide, and by the end global supplies of surgical masks were exhausted. Toronto was one of the cities most seriously affected and struggled to control the virus. “We couldn’t have handled another Toronto,” says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota in Minneapolis.

Ebola cases are expected to top 1 million by December, and the vast majority of these will be in West Africa. Most masks, gowns and gloves are made in China, and a lot more will be needed. “We have contacted the industry,” says Nuttall, but she could not say yet if they can increase production enough.

The reassurances now issuing from health agencies – that we are safe and can defeat anything – are perhaps understandable. Governments sing this refrain when they think the biggest need is to stop people panicking.

But panic isn’t the main problem. Our biggest need now is to mount a bigger and more urgent effort to stop the virus in Africa, and prepare for its arrival elsewhere.

Pretending the rich are safe as usual won’t drum up support for that effort. It also isn’t entirely true.